Mastering Endo-Laparoscopic and Thoracoscopic Surgery

Mastering Endo-
Laparoscopic and
Thoracoscopic Surgery
ELSA Manual
Davide Lomanto
William Tzu-Liang Chen
Marilou B. Fuentes
Editors
123
Mastering Endo-Laparoscopic and
Section Editor
Alembert Lee-Ong
Department of Surgery
Manila Doctors Hospital
Manila, Philippines
Section Editor
Emily Rose Nery
Department of Anesthesiology
The Medical City
Pasig, Philippines
Section Editor
Michael Lawenko
De La Salle Medical and Health Sciences
Dasmarinas, Philippines
Section Editor
Eva Lourdes Sta. Clara
Cardinal Santos Medical Center
San Juan, Philippines
Section Editor
Marilou B. Fuentes
The Medical City
Pasig, Philippines
Section Editor
Siau Wei Tang
National University Hospital
Singapore, Singapore
Section Editor
Narendra Agarwal
Department of Thoracic Surgery
Fortis Memorial Research Institute
Gurgaon, Haryana, India
Section Editor
Asim Shabbir
National University Hospital
Section Editor
Jaideep Rao
Mount Elizabeth Novena Hospital
Section Editor
Rajat Goel
Supreme Superspecialty Hospital
Faridabad, Haryana, India
Section Editor
Le Quan Anh Tuan

Department of Hepatobiliary and Pancreatic Surgery
Minimally Invasive Surgical Training Center
Ho Chi Minh City, Vietnam
Section Editor
Henry Chua
University of Cebu Medical Center
Cebu, Philippines
Section Editor
Rakesh Gupta
B.P. Koirala Institute of Health Science
Dharan, Nepal
Section Editor
Kiyotaka Imamura
Teine Keijinkai Hospital
Sapporo, Hokkaido, Japan
Section Editor
Enrico Lauro
General Surgery Division
St. Maria del Carmine Hospital
Rovereto, Italy
Section Editor
Hrisikesh Salgaonkar
Bariatric and Upper GI Surgery
University Hospitals of North Midlands N
Stoke-on-Trent, Staffordshire, UK
Section Editor

China Medical University Hsinchu Hospital
Zhubei, Taiwan
Section Editor
Sajid Malik
Allama Iqbal Medical College
Jinnah Hospital
Lahore, Pakistan
Davide Lomanto
Marilou B. Fuentes
Editors
Mastering
Endo-Laparoscopic and
ELSA Manual
Editors
Davide Lomanto William Tzu-Liang Chen
Department of Surgery Department of Surgery
Yong Loo Lin School of Medicine School of Medicine
National University of Singapore China Medical University
Singapore, Singapore Taichung City, Taiwan
Marilou B. Fuentes
The Medical City
Pasig, Philippines
MIS Education Asia
ISBN 978-981-19-3754-5 ISBN 978-981-19-3755-2 (eBook)

https://doi.org/10.1007/978-981-19-3755-2
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Foreword
Since its breakthroughs in 1990, minimally invasive surgery has changed sig-
nificantly the practice of general surgery as a result of the increasing number
of surgical procedures that can be carried out today with minimal discomfort
for the patient. These changes that occurred in the last decades have a great
impact also on the way we train and teach the upcoming generations of sur-
geons, surgical residents and trainees. Today, for all surgical trainees after
completing their basic surgical skills, lap training is mandatory to familiarize
themselves with the basic and then advanced laparoscopic procedures because
it will become an important part of their surgical future procedures.
Technologies like imaging systems, monitors and surgical energies that have
developed impressively with continuous evolution have not only made surgi-
cal procedures safer and faster but also allowed the surgeons to provide better
care and improved outcome for the patients. Indeed, all these changes and
evolution involved the entire staff of the operating theatre from our anaesthe-
tist colleagues to nurses. Many are involved in the development and dissemi-
nation of the minimally invasive procedure, and we hope that this
comprehensive manual will be a valuable tool to help the neophytes of all the
surgical specialties and those who are involved in MIS daily practice to sur-
mount the learning stage of endo-laparoscopic surgery.
The Endoscopic and Laparoscopic Surgeons of Asia, the ELSA, as society
and its members, has been charged with the responsibility to disseminate the
knowledge and to assure a proper standard of training, and we are sure that
with the experience of our leading experts involved in this manual we will
provide a high standard of educational tools for all surgeons and colleagues.
Davide Lomanto
Marilou B. Fuentes
v
Preface
In almost a century of surgery, few advances can be compared to the changes

brought by the introduction of minimally invasive surgery that represent a
true revolution in surgical practice for the greatest benefits offered to the
patients. Since the early 1990s, laparoscopic surgery has evolved signifi-
cantly covering all ranges of procedures from simple appendectomy to liver
and kidney transplantation. The obvious success was mainly due to the better
outcome and acceptance from patients for the several benefits. Today, some
procedures have been completely replaced by laparoscopic approach also
changing the way we teach and practice.
In fact, the revolution behind laparoscopic surgery also brings new con-
cepts in training and gaining proficiency; technological advancements were
introduced in training programmes like surgical simulators, virtual reality,
surgical preplanning, making space for new and more objective training pro-
gramme with full involvement of the surgical trainees in hands-on practice
and skills acquisitions. All tools that are mandatory and necessary are acces-
sible in current surgical training centres to enforce the skills needed for both
basic and advanced procedural training. But of course, all these activities
must complement also an active clinical practice with proctoring and
fellowship.
In a new panorama in surgical education, more online training programmes
are taking place either on online dedicated learning platforms or on social
media with all the pros and cons.
The decision to publish this manual is mainly to provide to all surgical
trainees and all surgeons that want to start endo-laparoscopic surgery a
Compendium of core information and knowledge and also pearls and tip to
learn and to improve their surgical skills.
This aim is fulfilled with the decision by the Endoscopic and Laparoscopic
Surgeons of Asia (ELSA) to make it available as open access for all.
This manual has been an effort of ELSA Experts and is organized in sec-
tions in which surgical technical aspects of each procedure is presented and
analysed from the procedural point of view. Our aim is to provide information
vii
viii Preface
in detail from patient’s preparation and OR setup to the surgical steps and
managements of complications.
We would like to extend our sincere appreciation to all the section editors,
authors our illustrators for their contributions who have been outstanding
throughout the editorial process and to our families for their continuous
support.
Singapore, Singapore Davide Lomanto

Taichung City, Taiwan William Tzu-Liang Chen
Pasig, Philippines Marilou B. Fuentes
Introduction
The historical development of laparoscopy can be traced back to early 1900s

when Georg Kelling from Dresden in Germany, performed a celioscopy by
inserting a Nitze cystoscope into the abdomen of a living dog after creating a
pneumoperitoneum using air. This was the beginning of laparoscopic era; his
study on physiology and anatomy together with the knowledge of using gas
to insufflate the abdomen was a pioneering achievement that took laparos-
copy forward. Hans Christian Jacobaeus, based on Kelling’s experience, per-
formed the first clinical laparoscopy and thoracoscopy in 1910, recognizing
the immense diagnostic and therapeutic possibilities of laparoscopic surgery.
A century ahead, we are now more technical and technological. With the
culmination of technological advances, laparoscopic surgery is ingrained in
our surgical practice, and we are able to perform diverse and complex laparo-
scopic procedures, also termed as minimally invasive surgery.
Laparoscopic surgery is defined by its three main components of image
production (light source, laparoscope, rod lens system or today’s electronic
imaging and camera), pneumoperitoneum—the insufflation of carbon diox-
ide gas to create space for operation and laparoscopic instruments. With this
combination, surgeons could perform diagnostic and some basic gynaeco-
logical procedures since the 1960s.
However, a major revolutionary shift in surgical practice and thinking
came in 1988 when Philippe Mouret from France performed the first laparo-
scopic cholecystectomy. Instead of removing the gallbladder through a
Kocher’s incision, he did it through a few small wounds each not larger than
1 cm. This exciting concept sparked intense developments in instrumentation,
innovation in advanced technical procedures, proliferation of training pro-
grammes and setting up of laparoscopic centres. We were indeed at the start
of a modern surgery era.
Laparoscopic surgery and conventional open surgery are today co-existing
and part of repertoire of any surgeons, so all young surgeon in training should
develop skills in. This brings us back to the objective of writing this Manual
for improvement in training and safety in practice.
Several procedures are totally being replaced by laparoscopic approach
like cholecystectomy that has replaced the traditional open approach in all
gallbladder disease as the new gold standard because it results in less postop-
erative pain, less postoperative pulmonary dysfunction, faster return of bowel
function, shorter length of hospital stay, faster return to normal activities and
ix
x Introduction
work and greater patient satisfaction. These benefits also generally extend to
other laparoscopic procedures.
The advantages mentioned, concludes the most obvious difference
between laparoscopic and open surgery- that of less surgical trauma to the
wound in laparoscopy. The access scar is minimized, leading to less pain, less
wound infection and dehiscence with better cosmetic result. In addition, lapa-
roscopy also reduces tissue trauma during dissection, and subsequent blood
loss, systemic and immune response and adhesive complications.
From the surgeon’s point of view, the projected image on the monitor is a
magnified image, resulting in better definition of structures. The smaller
wounds take shorter duration to close. And the video-recorded procedure can
be used for review and training purposes.
As in all surgical techniques and technologies, minimally invasive surgery
also has its limitations and disadvantages. First, one may encounter problems
during access into the abdominal cavity, such as iatrogenic injuries to the
bowel or major vascular structures. The incidence is about 0.05 to 0.1%. This
incidence can be reduced by practising the open technique of introduction,
rather than using the “blind” Veress needle technique and blunt-tipped tro-
cars. Second, there may be undesirable side-effects of carbon dioxide pneu-
moperitoneum, such as hypercarbia (see chapter on physiology of
pneumoperitoneum). And third, from the surgeon’s perspective, migration
from open to laparoscopic skills means that the 3D vision is reduced to mon-
ocular 2D vision on the screen, depth perception and field of view is much
reduced, and haptics, or the “feel” and tactile sensation of tissues, is limited
to gross probing of tissues. However, these limitations, once understood and
overcome, have not hampered the development of laparoscopy.
In a way, the surgeon is required to master a new set of skills to perform
laparoscopy safely. With training and experience, surgery can be performed
at a new standard that benefits patients.
Laparoscopy can now be performed in three main areas of the body—the
abdomen, the thorax, and closed spaces. Laparoscopy can be used to resect
tissues or to reconstruct tissues.
One can see that laparoscopy is widely applied. It is important, however,
to realize that for certain conditions laparoscopy is feasible but does not nec-
essarily replace open techniques. The practice will depend on the expertise
available and also on literature evidence that laparoscopy is superior to the
open approach.
Surgical training is the core reason for the conception of this training man-
ual. Surgeons in training are taught well-established skills in open surgery.
However, learning of laparoscopic skills is now becoming an increasingly
important part of the training programme because of the new set of skills that
need to be acquired. The main focus is to operate efficiently and minimize
surgical errors, i.e. operate safely. Training and constant practice are ways to
overcome the learning curve. A case point is the dramatic increase by three-
to fivefold in bile duct injuries in the early years when laparoscopic cholecys-
tectomy was performed by inexperienced and poorly trained surgeons; the
rate has since dropped to acceptable levels.
Introduction xi
Minimally invasive surgery, as it stands today, has been the result of

intense and continuous development and innovation on the part of surgeons
in techniques, private industries in instrumentation and in no small part by
public demands and patient requests. Surgical innovation will and should
continue, however, while maintaining a balance of not escalating costs of
healthcare delivery.
The progress of MIS will mirror that of developments in instrumentation
because technical innovation and expansion into previously “difficult” terri-
tories and advanced procedures has reached a plateau. With better and newer
instruments, procedures can be performed faster and more effectively, with
the potential of reducing operating duration and overall costs.
With progress in information technology (IT), mass data can be exchanged
faster along the Internet and 5G technologies, thus enabling more use of
broadcasting and teleproctoring to remote areas. Robotic devices have been
developed and today several devices are in the market ready to be used for all
procedures to assist in surgery and may one day also allow surgeons to oper-
ate from remote locations. And interconnectivity of information will stream-
line the process of surgery.
In conclusion, laparoscopy is a marriage of surgical skills, surgical innova-
tion and technology advancements. Training is at the core of improving sur-
geons so that patients benefit from the high quality of care given to them.
Davide Lomanto
Contents
Part I Basic Principles

Access, Pneumoperitoneum, and Complications�� 3
Eva Lourdes Sta Clara

Image Systems in Endo-Laparoscopic Surgery�� 7
Michael M. Lawenko and Angelica Feliz Versoza-Delgado

Care and Handling of Laparoscopic Instrumentations�� 15
Alembert Lee-Ong and Shirin Khor Pui Kwan

Electrosurgery and Energy Devices �� 19
Sajid Malik, Farah Khairi, and Sujith Wijerathne

Endo-Laparoscopic Suturing and Knotting: Tips and Tricks �� 25
Tuhin Shah
Ergonomics: An Overlooked Training �� 33
Tuhin Shah

Hemostasis in Laparoscopic Surgery �� 39
Ahmad Ramzi Yusoff and Davide Lomanto
Imaging-Enhancing System�� 45
Alembert Lee-Ong and Alfred Allen Buenafe
Instrumentations and Access Devices�� 51

Operating Room Setup and Patient Positioning in MIS�� 61

Surgical Smoke: Risks and Mitigation Strategies�� 69
Part II Anesthesia in Laparoscopic Surgery
Principles of Anesthesia�� 77
Emily Rose Nery

Physiologic Considerations in Laparoscopic Surgery�� 83
Alembert Lee-Ong
xiii
xiv Contents
Part III Diagnostic Laparoscopy

Staging Laparoscopy for Intra-Abdominal Carcinoma �� 89
Michael M. Lawenko
Diagnostic Laparoscopy�� 91
Michael M. Lawenko
Part IV Emergency Laparoscopy
Perforated Ulcer Treatment�� 95

Mika Yamamoto and Kiyotaka Imamura
Laparoscopic Appendectomy�� 99
Michael M. Lawenko and Eva Lourdes Sta Clara
Meckel’s Diverticula�� 103

Emergency Groin Hernia Repair �� 107
George Pei Cheung Yang
Laparoscopic Subtotal Cholecystectomy �� 115
Michael M. Lawenko

Adhesiolysis for Bowel Obstruction �� 119
Raquel Maia

Emergency Laparoscopic Small Bowel Resection�� 123
Abdul Gafoor Mubarak
Laparoscopic Hartmann’s Procedure�� 129
Yen-Chen Shao, Ming-Yin Shen, and William Tzu-Liang Chen
Part V Endocrine Surgery
Remote Access Endoscopic Thyroidectomy�� 139

Marilou B. Fuentes and Rainier Lutanco
Transoral Endoscopic Thyroidectomy �� 147
aparoscopic Adrenalectomy Abdominal Approach�� 153
L
Henry Chua and Vincent Matthew Roble II
Laparoscopic Adrenalectomy: Retroperitoneal Approach�� 161
Marilou B. Fuentes and Cheah Wei Keat
Part VI Breast Surgery

Endoscopy-Assisted Breast Surgery for Breast Cancer �� 169
Tang Siau Wei

Laparoscopic Omental Flap Partial Breast Reconstruction�� 175
Siau Wei Tang
Contents xv
Part VII Video Assisted Thoracic Surgery

Basic Principles and Advanced VATS Procedures�� 183
Narendra Agarwal and Bharti Kukreja
Part VIII Upper Gastrointestinal Surgery: Esophageal Surgery
Achalasia�� 201
Javier Lopez-Gutierrez and B. Mario Cervantes
Resection of Gastroesophageal Junction Submucosal
Tumors (SMTs)�� 207
Jun Liang Teh and Asim Shabbir

Transoral Endoscopic Zenker Diverticulotomy�� 213
Christina H. L. Ng and Chwee Ming Lim
Gastroesophageal Reflux Disease �� 219
Adam Frankel and B. Mark Smithers

Hiatal Hernia: Update and Technical Aspects�� 229
Andrea Zanoni, Alberto Sartori, and Enrico Lauro
Esophageal Cysts�� 237
Aung Myint Oo
McKeown Esophagectomy�� 243
Koji Kono
Part IX Upper Gastrointestinal Surgery: Gastric Surgery
Gastric Gastrointestinal Stromal Tumor �� 253

Danson Yeo and Jaideep Rao

Gastric Carcinoma: Subtotal and Total Gastrectomy�� 257
Danson Yeo
Part X Bariatric Procedures

Laparoscopic Gastric Banding for Morbid Obesity �� 273
Davide Lomanto, Emre Gundogdu, and Mehmet Mahir Ozmen
Laparoscopic Sleeve Gastrectomy�� 285
Sajid Malik and Sujith Wijerathne

Laparoscopic Roux EN y Gastric Bypass (LRYGB)�� 291
Rajat Goel, Chih-Kun Huang, and Cem Emir Guldogan

One Anastomosis Gastric Bypass (OAGB)�� 297
Hrishikesh Salgaonkar, Alistair Sharples, Kanagaraj Marimuthu,
Vittal Rao, and Nagammapudur Balaji
xvi Contents
Part XI Hepatobiliary Surgery: Gallbladder
Elective Cholecystectomy�� 307

Arnel Abatayo
Part XII Hepatobiliary Surgery: Common Bile Duct Stones

Laparoscopic Choledochotomy for Bile Duct Stones�� 315
Nguyen Hoang Bac, Pham Minh Hai, and Le Quan Anh Tuan
Part XIII Hepatobiliary Surgery: Liver
Hepatic Cyst/Abscess �� 321

Rakesh Kumar Gupta
Laparoscopic Wedge Liver Resection�� 331

Laparoscopic Left Liver Resection�� 335
Pham Minh Hai and Le Quan Anh Tuan
Laparoscopic Right Hepatectomy�� 339
Brian K. P. Goh
Part XIV Pancreas

Laparoscopic Internal Drainage of Pancreatic Pseudocysts�� 345
Le Quan Anh Tuan and Pham Minh Hai
Laparoscopic Distal Pancreatectomy �� 349
Laparoscopic Pancreaticoduodenectomy�� 357
Part XV Spleen
Laparoscopic Splenectomy�� 369

Marilou B. Fuentes and Davide Lomanto
Intraoperative Splenic Injuries�� 375
Part XVI Inguinal Hernia
Transabdominal Pre-peritoneal Approach (TAPP)�� 381


Totally Extraperitoneal Approach in Inguinal Hernia Repair�� 391
Davide Lomanto and Eva Lourdes Sta Clara
Contents xvii
Laparoscopic Management of Recurrent and Re-recurrent

Hernia�� 399
Sajid Malik, James Lee Wai Kit, Sujith Wijerathne,
and Davide Lomanto

Laparo-Endoscopic Approach to Complex Inguinal Hernia
[Inguinoscrotal Hernias: Sliding Hernias]�� 407
Rakesh Kumar Gupta and Davide Lomanto
Part XVII Incisional/Ventral Hernia Repair
Laparoscopic Intraperitoneal Onlay Mesh (IPOM)

and IPOM Plus�� 417
Extraperitoneal Ventral Hernia Repair �� 427
Kiyotaka Imamura and Victor Gheorghe Radu
Endoscopic Anterior Component Separation
Technique (eACS)�� 437
Role of Botulinum Toxin-A in Chemical Component
Separation Technique�� 443
Sajid Malik and Davide Lomanto

Endo-laparoscopic Repair of Lateral Ventral Hernia�� 449
James Lee Wai Kit, Sajid Malik, Sujith Wijerathne,
and Davide Lomanto
Part XVIII Diastasis Recti

Posterior Plication or Combined Plication of the
Recti Diastasis�� 459
Davide Lomanto, Raquel Maia, and Enrico Lauro
Endo-laparoscopic Retromuscular Repair�� 469
Enrico Lauro, Giovanni Scudo, and Salvatore Rizzo

Endoscopic Subcutaneous Onlay Laparoscopic Approach�� 475
Andreuccetti Jacopo, Di Leo Alberto, and Enrico Lauro
Part XIX Other Hernias

Minimally Invasive Surgery for Diaphragmatic Hernia�� 481
Hrishikesh Salgaonkar, Kanagaraj Marimuthu, Alistair Sharples,
Vittal Rao, and Nagammapudur Balaji

Laparoscopic Parastomal Hernia Repair�� 489
Isaac Seow-En, Yuan-Yao Tsai, and William Tzu-Liang Chen
xviii Contents
Part XX Colorectal Surgery
Laparoscopic Right Hemicolectomy with Complete Mesocolic

Excision and Central Vascular Ligation (CME/CVL)
for Right Sided Colon Cancer�� 499
Ming Li Leonard Ho and William Tzu-Liang Chen
Laparoscopic Left Hemicolectomy �� 505
Ming-Yin Shen, Yeen Chin Leow, and William Tzu-Liang Chen
Laparoscopic Anterior Resection �� 515
Elaine Hui Been Ng, Yeen Chin Leow,
and William Tzu-Liang Chen
Laparoscopic Abdominoperineal Resection�� 525
Isaac Seow-En and William Tzu-Liang Chen
Laparoscopic Total Colectomy�� 537
Mina Ming Yin Shen and William Tzu-Liang Chen
Laparoscopic Ventral Mesh Rectopexy�� 545
Isaac Seow-En, EmileTan Kwong-Wei,
and WilliamTzu-Liang Chen
Part XXI Robotic Surgery

Robotic Surgery: Operating Room Setup and Docking�� 555
Sajid Malik
Part XXII Other Laparoscopic Procedures
Laparoscopic Varicocelectomy�� 567

Rakesh Kumar Gupta

Laparoscopic Pediatric Inguinal Hernia Repair�� 573
Hrishikesh Salgaonkar and Rasik Shah
Editors and Contributors
About the Editors
Davide Lomanto graduated with distinction (Magna cum Laude) in medi-

cine and surgery in 1983 at the University of Rome “La Sapienza”, Italy. He
completed his training in general surgery in 1992 and his PhD in gastrointes-
tinal surgery in 1990 at the University of Rome “La Sapienza”, Italy, where
he subsequently became Associate Professor. He spent several periods of
time overseas for training in Switzerland, Germany and the USA.
Professor Lomanto is currently Professor of Surgery at the Yong Loo Lin
School of Medicine, National University of Singapore; Director of the
Minimally Invasive Surgical Centre (MISC) at the National University
Hospital (NUH) and Director of the Tan Sri Khoo Teck Puat Advanced
Surgery Training Centre (ASTC) at the National University of Singapore. He
is also a Senior Consultant in General Surgery and Paediatric Surgery at
NUH.
Professor Lomanto has a special interest in minimally invasive surgery,
laparoscopic digestive surgery including robotic and obesity surgery and
abdominal wall hernia repair. He is a fellow of international surgical societies
like SAGES, EAES, ACS and ELSA. He takes part in the organizing of the
International Surgical Congress and has been invited to speak and chair in
many international conferences. He received more than 15 awards for his
scientific studies at international congress. He is a member of the editorial
committee and reviewer of several scientific surgical journals.
Professor Lomanto is the Secretary-General and Past-President of the
Endoscopic and Laparoscopic Surgeons of ASIA (ELSA), founding member
and Advisory President of the Asia Pacific Hernia Society (APHS), founding
member and Past-President of the Asia-Pacific Metabolic and Bariatric
Surgery Society (APMBSS) and President of the Asia Endoscopic Task Force
(AETF). He is Secretary General and Treasurer of the International Federation
of Societies of Endoscopic Surgeons (IFSES).
Professor Lomanto has more than 150 publications in international peer-
reviewed surgical journals and more than 25 chapters in surgical books. He is
editor of 5 surgical books. He has been awarded the honorary membership of
the Surgical and Endolaparoscopic Societies of Japan (JSES), India (IAGES),
Indonesia (PBEI, PERHERI), Philippines (PCS, PALES), Thailand (RCST),
the European Association for Endoscopic Surgery (EAES) and the Royal
xix
xx Editors and Contributors
College of Surgeons of Edinburgh (FRCS). He is member of the International

Committee of the Consortium of American College of Surgeons Accredited
Education Institutes (ACS-AEIs). He serves as Managing Editor of Asian
Journal of Endoscopic Surgery, Associate Editor of Hernia Journal and inter-
national editorial member of Surgical Endoscopy and Asian Journal of
Surgery.
Professor Davide Lomanto attained his knighthood on 26 December 2009.
He was conferred the prestigious award Ordine della Stella della Solidarieta
Italiana by the Italian government for his leadership in clinical service,
research and academic recognition as expert in the field of surgery, minimally
invasive surgery and robotic surgery.
Marilou B. Fuentes is a consultant and the training officer of the Department

of Surgery at The Medical City Hospital, Manila, Philippines. She is a guest
faculty at the Ateneo School of Medicine and Public Health. Dr. Fuentes is a
fellow of Philippine College of Surgeons, Philippine Society of General
Surgeons and Philippine Association of Laparoscopic and Endoscopic
Surgeons and a member of Endoscopic and Laparoscopic Surgeons of Asia
(ELSA) and Asia Pacific Hernia Society (APHS).
William Tzu-Liang Chen is currently the superintendent of China Medical

University Hospital Hsin-Chu. After earning his medical degree in Taiwan, he
completed a research fellowship in colorectal surgery at the Cleveland Clinic
in Florida. Utilizing his training and clinical experiences, he has made nota-
ble contributions to literature regarding cutting-edge techniques of colorectal
minimally invasive surgery. Dr. Chen is also a charismatic speaker who has
been invited to present at over many international conferences. Along with
serving as a clinician and researcher, Dr. Chen is currently an associate pro-
fessor in the Department of Surgery, School of Medicine at China Medical
University, Taichung City, Taiwan.
Editor-in-Chief
Davide Lomanto, PhD, FAMS, FACS, FRCS Minimally Invasive Surgery

Centre, National University Hospital, Singapore, Singapore
General Surgery and Minimally Invasive Surgery, Department of Surgery,
National University Health System, Singapore, Singapore
Department of Surgery, YLL School of Medicine, National University
Singapore, Singapore, Singapore
Editors
William Tzu-Liang Chen Division of Colorectal Surgery, Department of

Surgery, China Medical University Hsinchu Hospital, Zhubei City, Hsinchu
County, Taiwan
Editors and Contributors xxi
Marilou B. Fuentes, FPCS, FPSGS, FPALES Department of Surgery, The

Medical City, Pasig, Manila, Philippines
Section Editors
Narendra Agarwal, MBBS MS, FCPS Department of Thoracic Surgery,

Fortis Memorial Research Institute, Gurgaon, India
William Tzu-Liang Chen Division of Colorectal Surgery, Department of
County, Taiwan
Henry Chua, MD, FPSGS, FPCS, FPALES, FACS Section of Minimally
Invasive Surgery, Cebu Doctors’ University Hospital, Cebu, Philippines
Advanced Minimally Invasive Surgery Fellowship Program, Cebu Doctors’
University Hospital, Cebu, Philippines
Advanced Minimally Invasive Surgery, Cebu Doctors’ University Hospital,
Cebu, Philippines
Eva Lourdes Sta Clara, FPCS, FPSGS, FPALES Training Officer
(UMIST) and Training Committee Department of Surgery, Cardinal Santos
Medical Center, Manila, Philippines
Department of Surgery, Rizal Medical Center, Manila, Philippines
Department of Surgery, Asian Hospital Medical Center, Manila, Philippines
Department of Surgery, University of Perpetual Help Dalta Medical Center,
Manila, Philippines
Marilou B. Fuentes, FPCS, FPSGS, FPALES Department of Surgery, The
Medical City, Pasig, Philippines
Faculty of Surgery, Philippine Board of Surgery, Ateneo School of Medicine
and Public Health, Manila, Philippines
Rajat Goel, MBBS, MS, DNB, MNAMS, FMIS, FMBS Supreme
Superspecialty Hospital, Faridabad, India
Aakash Healthcare Superspeciality Hospital, Dwarka, New Delhi, India
Rakesh Kumar Gupta, MS, FMAS GS & MIS Unit, Department of
Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
Kiyotaka Imamura Minimally Invasive Surgery Center, Yotsuya Medical
Cube, Tokyo, Japan
Enrico Lauro General Surgery Division, Santa Maria del Carmine Hospital,
Rovereto, Italy
General Surgery Division, St. Maria del Carmine Hospital, Rovereto, Italy
Michael M. Lawenko, MD, FPCS, FPSGS, FPALES De La Salle Medical
and Health Sciences Institute, Dasmarinas City, Philippines
xxii Editors and Contributors
Alembert Lee-Ong, FPCS, FPSGS, FPALES Department of Surgery,

Manila Doctors Hospital, Manila, Philippines
Philippine Center for Advanced Surgery, San Juan, Philippines
Department of Surgery, Cardinal Santos Medical Center, San Juan, Philippines
Department of Surgery, Quirino Memorial Medical Center, Quezon City,
Philippines
Sajid Malik, MBBS, FCPS, MRCS Department of General Surgery,
Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
Emily Rose Nery, DPBA, FPSA, FPSCCM Department of Anesthesiology,
The Medical City, Pasig, Philippines
Acute and Critical Care Institute, The Medical City, Pasig, Philippines
Department of Anesthesiology and Perioperative Medicine, Rizal Medical
Center, Pasig, Philippines
Jaideep Rao, MBBS, MRCS, MMED, FRCS, FAMS Mount Elizabeth
Novena Hospital, Singapore, Singapore
Hrishikesh Salgaonkar, DNB, MRCS Department of Bariatric and Upper
GI Surgery, University Hospitals North Midlands, Stoke-on-Trent, UK
Asim Shabbir, MBBS, MRCS, MMed, FCPS (Edin) National University
of Singapore, Singapore, Singapore
Siau Wei Tang, BMedSci, BMBS, MMed, MRCS, FRCS Division of
General (Breast) Surgery, Department of Surgery, National University
Hospital, Singapore, Singapore
Division of Surgical Oncology, National University Cancer Institute,
Le Quan Anh Tuan Department of Hepatobiliary and Pancreatic Surgery,
University Medical Center, Minimally Invasive Surgical Training Center, Ho
Chi Minh City, Vietnam
Department of General Surgery, University of Medicine and Pharmacy, Ho
Chi Minh City, Vietnam
Authors
Arnel Abatayo, MD, FPSGS, FPCS, FPALES Department of Surgery,

Chong Hua Hospital Mandaue, Cebu, Philippines
Di Leo Alberto General and Mini-Invasive Surgery, San Camillo Hospital,
Rovereto, Italy
Nguyen Hoang Bac Department of Surgery, University of Medicine and
Pharmacy, Ho Chi Minh city, Vietnam
Nagammapudur Balaji Department of Bariatric and Upper GI Surgery,
University Hospitals North Midlands, Stoke-on-Trent, UK
Editors and Contributors xxiii
Alfred Allen Buenafe, FPCS, FPSGS, FPALES Department of Surgery,

Rizal Medical Center, Pasig, Philippines
Philippine Center for Advanced Surgery, San Juan, Philippines
Department of Surgery, Cardinal Santos Medical Center, San Juan, Philippines
Department of Surgery, Batangas Medical Center, Batangas, Philippines
Department of Surgery, Asian Hospital and Medical Center, Alabang,
Muntinlupa, Philippines
B. Mario Cervantes Minimally Invasive Surgery and Robotic Surgery
CMN 20 de Noviembre, ISSSTE CDMX, Mexico city, Mexico
Adam Frankel, MD, PhD, FRACS, FRCSEd Upper Gastro-intestinal and
Soft Tissue Unit, Princess Alexandra Hospital, Brisbane, Australia
Brian K. P. Goh, MBBS, MMed, MSc, FRCSEd Department of
Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital
and National Cancer Centre Singapore, Singapore Liver Transplant Service,
SingHealth Duke-National University of Singapore Transplant Centre,
SingHealth Duke-NUS Liver Transplant Center, Duke-National University of
Singapore Medical School, Singapore, Singapore
Emir Guldogan, MD, FEBS Department of Surgery, Liv Hospital, Ankara,
Turkey
Pham Minh Hai Department of Hepatobiliary and Pancreatic Surgery,
University Medical Center, Ho Chi Minh city, Vietnam
Ming Li Leonard Ho Division of Colorectal Surgery, Department of
County, Taiwan
Chih-Kun Huang Body Science & Metabolic Disorders International
Medical Center, China Medical Hospital, Taichung, Taiwan
Andreuccetti Jacopo General Surgery 2, ASST Spedali Civili of Brescia,
Brescia, Italy
Cheah Wei Keat, MBBS, FRACS, FAMS, FACS General Surgery, Ng
Teng Fong General Hospital, Singapore, Singapore
Division of General Surgery (Thyroid and Endocrine Surgery), Department
of Surgery, University Surgical Cluster, National University Hospital, Kent
Ridge, Singapore
Farah Khairi General Surgery Services, Alexandra Hospital, Queenstown,
Singapore
James Lee Wai Kit Minimally Invasive Surgery Centre, National University
xxiv Editors and Contributors
Koji Kono, MD, PhD Department of Gastrointestinal Tract Surgery,

Fukushima Medical University, Fukushima, Japan
Shirin Khor Pui Kwan National University Hospital, Kent Ridge, Singapore
Yeen Chin Leow Colorectal Surgery Unit, Department of Surgery, Hospital
Sultanah Bahiyah, Alor Star, Malaysia
Division of Colorectal Surgery, Department of Surgery, China Medical
University Hospital, Taichung, Taiwan
Chwee Ming Lim, MBBS, MRCS, MMed Department of
Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital,
Surgery Academic Clinical Programme, Duke-NUS Medical School,
Javier Lopez-Gutierrez, FACS Minimally Invasive Surgery and
Gastrointestinal Endoscopy CMN 20 de Noviembre, ISSSTE CDMX,
Mexico City, Mexico
Rainier Lutanco, FPCS Department of Surgery, The Medical City, Pasig,
Manila, Philippines
Raquel Maia Brazilian College of Gastric Surgeons, Sao Paulo, Brazil
Kanagaraj Marimuthu Department of Bariatric and Upper GI Surgery,
University Hospitals North Midlands, Stoke-on-Trent, UK
Abdul Gafoor Mubarak, MD, MBBS, MS, MRCSED, MMED Island
Hospital, Penang, Malaysia
Christina H. L. Ng, MBBS, MRCS, MMed Department of
Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital,
Elaine Hui Been Ng Colorectal Surgery Unit, Department of Surgery,
Hospital Raja Permaisuri Bainum, Ipoh, Malaysia
Division of Colorectal Surgery, Department of Surgery, China Medical
Mahir Ozmen, MS, FRCS, FACS, FASMBS Department of Surgery,
Medical School, Istinye University, Istanbul, Turkey
Aung Myint Oo, Upper GI, Bariatric and Metabolic Surgery, Department of
General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
Victor Gheorghe Radu Medlife, Bucharest, Romania
Vittal Rao Department of Bariatric and Upper GI Surgery, University
Hospitals North Midlands, Stoke-on-Trent, UK
Salvatore Rizzo General Surgery Division, Cavalese Hospital, Cavalese,
Italy
Editors and Contributors xxv
Vincent Matthew Roble II, MD, FPSGS, FPCS Advanced Minimally

Invasive Surgery Fellowship Program, Cebu Doctors’ University Hospital,
Cebu, Philippines
Advanced Minimally Invasive Surgery, Cebu Doctors’ University Hospital,
Cebu, Philippines
Giovanni Scudo General Surgery Division, St. Maria del Carmine Hospital,
Rovereto, Italy
Alistair Sharples Department of Bariatric and Upper GI Surgery, University
Hospitals North Midlands, Stoke-on-Trent, UK
Isaac Seow-En Department of Colorectal Surgery, Singapore General
Division of Colorectal Surgery, China Medical University Hospital, Taichung,
Taiwan
Rasik Shah, MCh SRCC Children’s Hospital, Narayana Health, Mumbai,
India
Tuhin Shah, MS, FACS Department of Surgery, Manmohan Memorial
Medical College, Kathmandu, Nepal
MISC Department of Surgery, National University Hospital, Kent Ridge,
Singapore
Ming-Yin Shen Division of Colorectal Surgery, Department of Surgery,
China Medical University Hsinchu Hospital, Zhubei City, Hsinchu County,
Taiwan
Mina Ming Yin Shen Division of Colorectal Surgery, Department of
County, Taiwan
B. Mark Smithers, AM, MBBS, FRACS, FRCSEng, FRCSEd Upper
Gastro-intestinal and Soft Tissue Unit, Princess Alexandra Hospital, Brisbane,
Australia
Academy of Surgery, The University of Queensland, Brisbane, Australia
Jun Liang Teh, MBBS, MMED, ChM (Edin), FRCEsd Ng Teng Fong
General Hospital, National University Health System, Singapore, Singapore
Angelica Feliz Versoza-Delgado, MD, DPBS Department of Health
Informatics, De La Salle Medical and Health Sciences Institute, Dasmarinas
City, Philippines
Danson Yeo, MBBS, MRCS, MMed, FRCSEd Upper Gastrointestinal and
Bariatric Surgery, Department of General Surgery, Tan Tock Seng Hospital,
xxvi Editors and Contributors
Sujith Wijerathne, MBBS, MRCS, MMed, FRCS, FAMS Minimally

Invasive Surgery Centre, National University Hospital Singapore, Singapore,
Singapore
General Surgery Services, Alexandra Hospital, Queenstown, Singapore
Mika Yamamoto Department of Surgery, Teine Keijinkai Hospital, Sapporo,
Japan
George Pei Cheung Yang Hong Kong Hernia Society, Hong Kong, China
Hong Kong Adventist Hospital, Hong Kong, China
Ahmad Ramzi Yusoff, MBBCh, MSurg, MRCS Department of Surgery,
Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
Department of Surgery, Universiti Teknologi MARA, Sg. Buloh, Selangor,
Malaysia
Part I
Basic Principles
Access, Pneumoperitoneum,
and Complications
Creating a pneumoperitoneum, the safe way is that Raoul Palmer introduced its use in estab-
one of the first steps a surgeon should learn in lishing pneumoperitoneum for laparoscopy
doing laparoscopic surgeries. As with any proce- [1].
dure, there is risk of complications which might It has an outer cannula with a beveled needle
occur like bleeding, subcutaneous emphysema, and a spring-loaded inner stylet with a dull tip
vascular injuries, and bowel injuries in accessing which retracts as the needle goes through the
the abdomen. abdominal wall and pushes forward once it is
The purpose of this chapter is to discuss the inside the abdominal cavity to protect the under-
four techniques in establishing pneumoperito- lying viscera. Its length ranges from 7 to 15 cm
neum namely the Veress needle technique, direct with a diameter of 2 mm.
trocar insertion, optical trocar insertion, and open Technique: A small incision is made superior
(Hasson’s) technique. The choice as to which or inferior to the umbilicus just enough for the
technique to choose depends on the surgeon’s veress needle to pass through. The patient is then
preference, habitus of the patient, and anticipated placed in Trendelenburg’s position and the
previous postoperative conditions like adhesions. abdominal wall is lifted using towel clamps at the
sides of the umbilicus to create negative pressure.
The needle is then inserted with the tip towards
Veress Needle Technique the pelvis to prevent injuries to bowels and ves-
sels. A “give” will be felt once it enters the peri-
The Veress needle (Fig. 1) was invented by
Janos Veress in 1930 as a tool for treating
patients with tuberculosis. It was only in 1947,
E. L. Sta Clara (*)

Training Officer (UMIST) and Training Committee
Department of Surgery, Cardinal Santos Medical
Center, Manila, Philippines
Department of Surgery, Rizal Medical Center,
Manila, Philippines
Department of Surgery, Asian Hospital Medical
Department of Surgery, University of Perpetual Help
Dalta Medical Center, Manila, Philippines
Fig. 1 Veress needle
© The Author(s) 2023 3
D. Lomanto et al. (eds.), Mastering Endo-Laparoscopic and Thoracoscopic Surgery,
https://doi.org/10.1007/978-981-19-3755-2_1
4 E. L. Sta Clara
toneal cavity. Avoid moving side to side the

needle as this may enlarge a bowel or vessel
perforation.
Correct placement of the needle can be veri-
fied by injecting saline solution and there should
be no resistance. It can also be checked by the
sudden escape of air from the abdominal cavity
and drop test.
Low flow insufflation of CO2 is then started
until the intraabdominal pressure reaches
13–15 mm Hg. The needle is then replaced with
a sharp trocar and the scope is used immediately
to verify the correct entry. The other trocars are
then inserted under direct vision.
If midline adhesions are anticipated, another
location to insert the Veress needle is at Palmer’s
point. This is located 3 cm below at left subcostal
area at the midclavicular line [1]. This is recom-
mended for obese and very thin patients. Fig. 2 Hollow trocar with transparent tip
ing movement. The transparent tip allows direct

Direct Trocar Insertion visualization and allows the user to see the differ-
ent abdominal layers as the trocar goes through
Direct trocar insertion was first described by the abdomen until the peritoneal cavity is reached.
Dingfelder in 1978. Advocates of this technique
prefer this because it excludes the use of a Veress
needle thus avoiding double-blind puncture of Open (Hasson) Technique
the abdomen and is the fastest [2]. However, this
must be carried out by experienced and skilled Open technique was first described by Hasson in
surgeons because it is a blind direct insertion. 1971. This technique lessens the probability of
Prerequisites to this technique are adequate skin visceral or vascular injuries which are more com-
incision, sharp trocar, and a completely relaxed monly encountered in blind techniques [3].
abdominal wall. The abdominal wall is lifted A 2 cm incision is made at the umbilicus or
with towel clamps at the trocar and is inserted in either superior or inferior to the umbilicus. The
a twisting motion. The trocar is held like a pen to fascia and the peritoneum are incised, and the
avoid accidentally going too deep and inadver- peritoneal cavity is entered under direct vision.
tently perforating bowels or vessels. The scope is Finger exploration around the periumbilical area
then used, and an explorative laparoscopy is then is sometimes done to determine if there are
done to check for injuries. abdominal adhesions. The Hasson’s trocar
(Fig. 3) is then inserted and anchored with stay
sutures at the fascia. The scope is then inserted to
Optical Trocar Insertion verify correct position of the trocar and to look
for any injuries. Insufflation of CO2 is then initi-
Optical trocars as seen in Fig. 2 have a hollow ated at low pressure. Rapid expansion of the dia-
shaft with a transparent tip. An adequate skin phragm might lead to vagal stimulation and
incision is made then a zero-degree telescope is bradyarrhythmias. The open technique is recom-
inserted through the trocar as the surgeon inserts mended especially for patients with previous
the trocar through the abdominal wall in a rotat- abdominal operations.
Access, Pneumoperitoneum, and Complications 5
creation of the pneumoperitoneum. One should sus-

pect that the gas is going extraperitoneally if there is
no obliteration of the liver dull sounds and the CO2
pressure does not rise. Conversion to open
(Hasson’s) technique is advisable if there is diffi-
culty in positioning the Veress needle safely.
Vascular injury has a low incidence rate of
Fig. 3 Hasson’s trocar 0.04% however this is the most life-threatening
[5]. Immediate surgical intervention is required
and conversion to open laparotomy and subse-
Pneumoperitoneum quent vascular repair is done. The most common
vessels injured during the blind entry of the first
Creation of the pneumoperitoneum and mainte- trocar are the following: abdominal aorta, iliac
nance of it is essential in laparoscopic surgery. vessel at the level of the aortic bifurcation, and
Otherwise, one will not have adequate working inferior vena cava. Vascular injuries usually occur
space. The ideal insufflating gas should be cheap, during uncontrolled forced entry.
physiologically inert, colorless, have high blood Another complication is visceral injury. It has
solubility, and is nonexplosive. Some of the a 0.13% incidence but the mortality rate can go as
insufflating agents are carbon dioxide, nitrous high as 3.6% [6]. Whenever this is suspected it is
oxide, helium, and argon. However, the most crucial to determine immediately the location. A
used one is carbon dioxide since it is cheap, has complete bowel examination is mandatory, and
low toxicity, is easily reabsorbed, has a low risk the injury is sutured via open laparotomy, mini-
of gas embolism, and is nonexplosive [4]. laparotomy, or laparoscopy. This can be repaired
Insufflation is achieved by using an insufflator based on its severity and the surgeon’s choice.
which delivers carbon dioxide at a flow rate of up to
20 L/min. The insufflator also has an alarm which
sounds when the abdominal pressure exceeds the References
predetermined level, which is set at 12–15 mm Hg.
Higher pressures may lead to hypercarbia, acidosis, 1. Palmer R. Safety in laparoscopy. J Repro Med.
1974;13:1–5.
and adverse hemodynamic and pulmonary effects. 2. Dingfelder JR. Direct laparoscopic trocar insertion
without prior pneumoperitoneum. J Reprod Med.
1978;21:45–7.
Complications and Management 3. Hasson HM. A modified instrument and method for
laparoscopy. Am J Obstet Gynecol. 1971;110:886–7.
4. Neuhaus SJ, Gupta A, Watson DI. Helium and other
As in any procedure, there will always be a risk of alternative insufflation gases for laparoscopy. Surg
complications, which ranges from 0.05 to 0.2%. Endosc. 2014;15:553–60.
However, this represents about 20–30% of the com- 5. Molloty et al. Laparoscopic entry: a literature review
and analysis of technique and complications of pri-
plications encountered in laparoscopic surgery. This mary port entry. Aust N Z J Obstet Gynaecol 2002.
may be namely bowel injury, vascular injury, and 6. der Voort V, EAM H, Gourma DJ. Bowel injury as
extraperitoneal gas insufflation. The most common complication of laparoscopy. BJS. 2004;91:1253–8.
is extraperitoneal gas insufflation, which can be pre-
vented by inserting the Veress needle perpendicu-
larly and making sure it is in place during the
6 E. L. Sta Clara
Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License
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obtain permission directly from the copyright holder.
Image Systems
in Endo-Laparoscopic Surgery
Michael M. Lawenko
and Angelica Feliz Versoza-Delgado
Introduction Telescope
The field of minimally invasive surgery (MIS) There are two common types of endoscope: One
has seen tremendous growth and advancement using standard Rod-lens system and the other is a
since its advent in the 1980s. New procedures, fully digital scope using a camera chip on the tip
MIS techniques, and instruments are evolving of the rigid or flexible endoscope.
regularly which makes it important for surgeons The conventional Endoscope is made of surgi-
to be familiar with these developments. MIS is a cal stainless steel and contains a series of optical
technologically dependent specialty and every lens comprised of precisely aligned glass lenses
surgeon is expected to have good background and spacers (so-called Rod Lens System). It con-
knowledge of new instruments and imaging sys- tains an objective lens, which is located at the
tems. Endo-laparoscopic surgery is conducted distal tip of the rigid endoscope, which deter-
using an array of imaging devices that are all mines the viewing angle. The light post at right
interconnected. Basic components of the image angles to the shaft allows attachment of the light
systems in endo-laparoscopy include a telescope cable to the telescope. The eyepiece or ocular
connected to a light source and a controller unit. lens remains outside of the patient’s body and is
The images are then transmitted through a moni- attached to a camera to view the images on a
tor that allows the surgical team to visualize the video monitor.
operative field. Documentation of the surgical Telescopes or laparoscopes come in various
procedure, both real-time and recorded, can be diameters. The 10 mm diameter is the most com-
achieved through a video recording hub and/or monly used scope and provides the greatest light
printer. and visual acuity. Other varieties are the 5 mm
and 2–3 mm needlescopes which is mostly used
in children. Full screen 5 mm laparoscopes capa-
ble of providing images comparable to 10 mm
systems are now available in the market. Various
M. M. Lawenko (*) visualization capabilities such as a 0° forward
De La Salle Medical and Health Sciences Institute, viewing, 30 or 45° telescope are the varieties
Dasmarinas City, Philippines (Fig. 1).
e-mail: mmlawenko@dlshsi.edu.ph Advances in digital endoscopy utilizes a chip
A. F. Versoza-Delgado on the tip (CMOS or CCD) of a rigid videolapa-
Department of Health Informatics, De La Salle roscope (e.g., Endoeye Olympus™) or flexible
Medical and Health Sciences Institute,
Dasmarinas City, Philippines endoscope. There is no longer an interface
https://doi.org/10.1007/978-981-19-3755-2_2
8 M. M. Lawenko and A. F. Versoza-Delgado
Fig. 1 10 mm forward oblique telescope (30°)
between the camera head and the endoscope, and

traditional rod lenses are no longer used. In lieu
of this, a distally mounted image sensor with a
lens is used. This delivers better resolution and
clarity of images. It also offers a focus-free and
better ergonomic design. These scopes are also
autoclavable.
Fig. 2 Xenon light source (Olympus VISERA ELITE™)

Light Source
This is critical for visualization of the operative

field. A typical light source is composed of a
lamp or bulb, a condensing lens, a heat filter, and
an intensity-controlled circuit. Light quality is
dependent on the type of lamp that is used. Most
light sources nowadays use the high-intensity
xenon light source which provides white light
illumination (Fig. 2). The previous light sources
used a quartz halogen bulb, incandescent bulbs,
and metal halide vapor arc lamps.
Newer light sources have incorporated the use
of LED technology. An LED light source is able
Fig. 3 Fiberoptic light cable
to deliver cold, white light that generates virtu-
ally no heat. These light sources are energy-
efficient and noiseless. Compared to Xenon light The principle of fiberoptic cables is based
sources (Fig. 2), LED light sources offer up to on the total internal reflection of light wherein
30,000 h of service life and therefore do not light would enter one end of the fiber after
require lamp changes. numerous internal reflections and go out
through the other end with virtually all its
Light Cable strength intact. Fiberoptic cables are flexible
Light is transmitted from the lamp to the laparoscope but do not transmit a precise light spectrum.
through cables (Fig. 3). The two types of cables are They have a very high quality of optical trans-
the fiberoptic and the liquid crystal gel cable. mission but are fragile.
Image Systems in Endo-Laparoscopic Surgery 9
Liquid crystal gel cable is composed of a laparoscopic use contains 250,000–380,000 pix-
sheath that is filled with a clear gel. These cables els. The single-chip camera has a composite
are capable of transmitting more light than optic transmission in which three colors of red, blue,
fibers. They can transmit a complete spectrum and green are compressed into a single chip. The
but are more rigid and fragile. Liquid crystal gel three-chip camera has a separate chip for each
cables require soaking for sterilization and can- color with a high resolution. The clarity of the
not be gas sterilized. image eventually displayed or recorded will also
depend on the resolution capability of the moni-
tor and the recording medium. The resolution is
Camera Head (From 2D to 3D defined as the number of vertical lines that can be
Technology) discriminated as separate in three quarters of the
width of the monitor screen. Standard consumer-
Since the advent of laparoscopy, technologies in grade video monitors have 350 lines, monitors
camera systems have quickly evolved. A few with about 700 lines are preferred for
decades ago, the main technology utilized in laparoscopy.
minimal access surgery was the charged coupled Three-dimensional (3D) cameras have been
device. Now, two new systems are at the cutting developed to overcome the lack of depth percep-
edge of surgical video technology: 3D and tion in traditional 2D laparoscopy. In 3D laparos-
UHD/4 K. These systems were developed with copy, different images are presented to each of
the goal of providing better imaging and better the surgeon’s eyes to facilitate stereopsis. This is
depth perception. accomplished using two different technologies:
The traditional camera for endo-laparoscopic by a single channel laparoscopes with one system
surgery (Fig. 4) contains a solid-state silicon chip of lenses, then using a digital filter to separate the
or the charged coupled device (CCD). This essen- images for each eye; another system utilizes a
tially functions as an electric retina and consists dual channel laparoscopes with one lens system
of an array of light-sensitive silicon elements. for each eye, this provides a real and better ste-
Silicon emits an electrical charge when exposed reovision (Fig. 5).
to light. These charges can be amplified, trans- In both technologies, it is necessary for the
mitted, displayed, and recorded. Each silicon ele- surgeons and the OR Staff to wear passive or
ment contributes one unit (referred to as a pixel) active stereoscopic glasses to visualize the 3D
to the total image. The resolution or clarity of the Image (Fig. 6a–c).
image depends upon the number of pixels or light The eyepieces which may be shutter glasses,
receptors on the chip. Standard cameras in endo- head mounted displays/headsets or passive polariz-
Fig. 4 HD camera head

Fig. 5 Dual channel telescope with two images one for each eye
a b
Fig. 6 (a) Anaglyph lens (not for medical use), (b) Passive polarization lens for medical use, (c) OR team wearing
passive lenses
3D polarized glasses
For 3-dimensional
image viewing
3D Image Display
left image
3D Monitor right image
3D Camera Control Unit

Image enhancement
Image sensors in camera head

Conversion of optical into
electronic signals
Fig. 7 3D technology in laparoscopy (Aesculap EinsteinVision®)
ing glasses are the most commonly utilized.

Disadvantages of 3D laparoscopy involve a higher
cost of video systems, need to wear 3D glasses, and
eye fatigues even though the evolution of a new 3D
system in the last decade have reduced most of the
side effects and improved sensibly the quality of the
image (Fig. 7). On the other side better accuracy Fig. 8 Flexible tip telescope for angled vision
and performance, easier depth judgment, and better
identification of structure at different depth levels monitors. This indirectly provides a better depth
have been shown in several studies that improve perception due to improved clarity and light reac-
significantly surgical performance, reduce fatigue, tion to the anatomic structures.
and are helpful in demanding tasks like suturing and Certainly, evolution will continue for surgical
fine dissection with an overall reduced time for imaging with 8 K in development and may be
skills acquisition. further higher resolution to provide an even bet-
Similar to a fixed 0° 3D telescope, there was a ter visual experience superior to reality.
development of a flexible tip fiberoptic telescope
to overcome the lack of angled vision (Fig. 8).
The challenges of 3D Image adoption and the Controller Unit
evolution in imaging for both professional and
consumers has also evolved in the medical field The function of the controller unit is to capture
with the advent of 4 K technology. After an initial and process the video signals taken by the tele-
shifting from standard definition to high defini- scope and camera head to the video monitor to
tion (1920×1080) today more surgeons utilized provide an accurate visualization of the operative
the 4 K technology in which resolution is field. It also functions to convert gathered video
3840×2160 that allow the use of larger monitor signals to digital HD images or downgrade it to
(40″–65″ and bigger) with an incredible percep- standard definition (SD) images.
tion of the fine anatomical details. Fine structure The control unit is attached to the camera head
that is used to be blurred in HD become clearer in in its front console while connections to the video
4 K and no more pixelation effect on the large monitor are at the back panel. Connection to the
Fig. 9 Video system center unit with both image proces-

sor and light source
Fig. 10 4 K image quality
video monitor is in the form of digital cables

which are the digital video interface (DVI) for the
HD image and the serial digital interface (SDI)
for the SD image. Newer controller units com-
bine both image processor and light source func-
tions in one unit (Fig. 9).
Video Monitor
High-resolution liquid crystal display (LCD)

monitors are suitable for the reproduction of
endoscopic image. This is a type of monitor
wherein grids of liquid crystals are arranged in
RGB (red-green-blue) triads in front of a light
source to produce an image. In general, the reso-
lution capability of the monitor should match that
of the video camera. Three chip cameras require
monitors with 800–900 lines of resolution to
realize the improved resolution of the extra chip
sensors. Two separate monitors on each side of
the table are commonly used for laparoscopic
procedures. The use of special video carts for Fig. 11 LED video monitor
housing the monitor and other video equipment
allows greater flexibility and maneuverability.
A larger screen displaying the same number of in different sizes ranging from 40–55 in. This
pixels will have a lower spatial resolution com- optimizes the surgeon’s performance in mini-
pared to a smaller screen since the resolution is mally invasive surgery. With these features, 4 K
dependent on the pixel density. The advantage of systems are being used as an alternative to the
ultra high definition UHD-4 K technology in lap- passive polarizing 3D display systems.
aroscopy monitors is it allows the image to be Some medical-grade monitors are now
displayed on a larger screen of up to 55 in with- equipped with LED (light-emitting diode) or
out compromising the resolution of 4098 × 2160 OLED (organic light-emitting diode) technology.
pixels (Fig. 10). Larger 4 K screens are available LED monitors (Fig. 11) also feature a liquid crys-
tal display panel to control where light is dis- Integrated Operating Room
played on the screen, but the backlighting is
produced using more efficient LEDs instead of As surgical equipment continues to modernize,
fluorescent lamps. When used in endo- advanced operating theaters (OT) are now using sys-
laparoscopy, these monitors are able to produce tems integration (Fig. 13). This functionally connects
an extremely detailed image representation of the the OT environment including the patient informa-
operative field. They offer several advantages tion system, audio, video, surgical lights, and other
which include high resolution, excellent image aspects of building automation. When integrated, all
response times, and more precise and faithful the technology used in the OT can be controlled
color reproduction compared to traditional LCD through a single command console by a single opera-
monitors. tor. This provides seamless connections between
equipment and personnel inside and out of the OT. To
improve the space within the OT, devices are mounted
Documentation on movable arms or carts that can swing around the
patient to optimize visualization. These mounts allow
A video recorder or a printer can be utilized proper positioning of the monitors and image sys-
for documentation during a surgical proce- tems in relation to the different areas of the patient’s
dure. Today, both digital videos and images body during a surgical procedure. Integration allows
can be captured either on a medium like not only a centralized control of the different units but
CD-DVD or digitally like a hard drive, USB, also interaction with any external party like Meeting
etc. The standard documentation equipment Rooms, Conference Centre, or for any other educa-
housed in the video card has multiple functional purpose. This avoids unnecessary visitors
tions. First, a digitally recorded file can be within the sterile operating field.
transferred to an optical media device such as
a digital video disc (DVD). Second, video
snapshots taken during a procedure can be
printed on a digital printer.
Recent technology available for intraoperative
documentation provides full HD for still/video
images along with two-channel, simultaneous
real-time recording. It has the capability of pro-
cessing records, managing images as well as edit-
ing (Fig. 12). Fig. 12 Image management hub
Fig. 13 Example of integrated operating room (Hexavue™ Integration System)

Further Reading Schwab K, et al. Evolution of stereoscopic imaging in

surgery and recent advances. World J Gastrointest
Endosc. 2017;9:368–77.
3D Technology in Laparoscopy. https://www.bbraun.com/
Siddharth V, Kant S, Chandrashekhar R, Gupta
en/products-and-therapies/laparoscopic-surgery/3d-
SK. Integration in operation theater: need of the
technology-in-laparoscopy.html.
hour. Int J Res Foundation Hosp Healthc Adm.
Destro F, et al. 3D laparoscopic monitors. Med Equip
2015;3(2):123–8.
Insights. 2014;5:9–12.
Sørensen SMD, et al. Three-Dimesional versus two-
Ohuchida K, et al. New advances in three-dimensional
dimensional vision in laparoscopy: a systematic
endoscopic surgery. J Gastrointest Dig Syst. 2013;3:152.
review. Surg Endosc. 2016;30:11–23.
Olympus Endoeye. https://www.olympus-europa.com/
medical/rmt/media/en/Content/Content-M SD/
Documents/Brochures/HD_EndoEye_EN_201303.pdf
Care and Handling of Laparoscopic
Instrumentations
Alembert Lee-Ong and Shirin Khor Pui Kwan
Introduction Care and Handling of Telescopes
Laparoscopic instrumentation ranging from The telescope is the most expensive and fragile
operating telescopes and fiber optic light cables component of laparoscopic instrumentation. It is
to surgical instruments represents a substantial also an integral part of the instrumentation, pro-
investment for the operating theater department viding image and light through two distinct sys-
[1, 2]. The delicate nature of these devices and tems. As such, telescopes must be handled with
the high cost involved in the acquisition and sub- care from the start to the end of the surgery, and
sequently to maintain or repair them when dam- also during the cleaning and sterilization
aged, warrants surgeons, nurses, and reprocessing process.
personnel to handle them carefully and appropri- All surfaces of a telescope should be inspected
ately at all times. Proper care and handling of regularly for any scratches, dents, or other flaws.
laparoscopic instrumentation can help to prolong The telescope should also be inspected before
their lifespan and maintain them at an optimal each use to assess functional integrity. The eye-
performance level. With the goal of delivering the piece should be examined to evaluate the clarity
finest in-patient care, all surgical team members of the image from the reflected light. In addition,
and reprocessing personnel must be familiar with it is also important to check the optical fibers sur-
the use of and recommendations for care and rounding the lens train at the tip of the telescope
handling of all laparoscopic instrumentation. by holding the light post toward a bright light. If
the image is discolored or hazy or there is the
presence of black dots or shadowed areas, it may
be due to improper cleaning, a disinfectant resi-
due, a cracked or broken lens, the presence of
A. Lee-Ong (*) internal moisture, or external damage.
Department of Surgery, Manila Doctors Hospital,
Manila, Philippines When using a metal cannula, the telescope
should be inserted gently into the lumen, so as
Philippine Center for Advanced Surgery,
San Juan, Philippines not to break or scratch the lens. At any point of
time during use or cleaning and disinfection pro-
Center, San Juan, Philippines cess, the telescope should not be bent during han-
dling, and avoid placing any heavy instruments
Department of Surgery, Quirino Memorial Center,
Quezon City, Philippines on top of the telescope. The telescope also should
never be placed near the edge of a sterile trolley
S. K. P. Kwan
National University Hospital, Kent Ridge, Singapore or surgical field to prevent it from accidental
https://doi.org/10.1007/978-981-19-3755-2_3
16 A. Lee-Ong and S. K. P. Kwan
dropping onto the floor. When transferring the desired tissue effect is needed. Damage to the
telescope from one point to another, it is best insulation results from a combination of physical
done by gripping the ocular lens in the palm and insult, mechanical degradation, cleaning, tem-
never by the shaft. Immediately after use, wash perature cycling from repeated sterilization, and
the surfaces of the telescope with a soft cloth or high-voltage corona heating [3–5].
sponge using a neutral pH enzymatic solution Insulation failures can result in inadvertent
and a thorough rinse with distilled water to electrosurgical injuries by providing alternate
remove any residual cleaning solution. pathways for the current; these breaks need not
be large, as the current density is inversely pro-
portional to the area size of the break which it
Care and Handling of Light Cables passes. A good portion (18%) of these insulation
failures have been detected in the segment
Another important component of laparoscopic described as “Zone 2” by Voyles and Tucker;
instrumentation is the use of a light source cable proximal to the segment in view by the monitor
to transmit light through the telescope to view the but outside of the port cannula and is likely to
operative field. Light cables are made of hun- cause devastating injuries.
dreds of glass fibers to transmit the light, and Visual inspection of the insulation sheath is
these fibers can be broken if the cable is dropped, suggested before use, after use, and after the pro-
kinked, or bent at extreme angles. Following are cessing of the instruments [6]. Some instrument
some general guidelines regarding the care and manufacturers have designed the insulation in
maintenance of light cables: double layers, the underlying brighter colored
layer ease detection of a break in the outer layer.
• Avoid squeezing, stretching, or sharply bend- However, only 10% of insulation failures are
ing the cable. detected visually.
• Grasp the connector piece when inserting or The use of a current leak or insulation break
removing the light cord from the light source. detector improved break identification, Yaznadi
Never pull the cable directly when disconnect- and Krause [3] noted a significant decrease in the
ing it from the light source. prevalence of insulation breaks after an institu-
• Avoid puncturing the cable with towel clips, tion established routine testing with such a
when securing the cables to the surgical drape. device.
• Do not turn the light source on before con-
necting the light cable to the telescope to pre-
vent igniting a fire on the surgical drape. Cleaning, Disinfecting,
• Inspect the cable for broken fibers before each and Sterilizing of Laparoscopic
use. Instruments
• Inspect both ends of the cable to ensure they
have a clean, reflective, and polished surface. Reprocessing laparoscopic instruments is one of
• Wipe the fiber optic light cable gently to the toughest challenges to OR personnel today.
remove all blood and organic materials imme- These instruments are extremely difficult to clean
diately after use using a mild detergent. because of their long shaft and complex jaw
assemblies, which may trap infectious bioburden
and debris. The positive pressure of the CO2 in
Insulation Care the insufflated abdomen may also cause blood
and other body fluids to flow up into these chan-
The majority of laparoscopic instruments have an nels, and making them difficult or impossible to
insulation sheath; this isolates the current flow remove. Many of these instruments cannot be
along the hand instrument from the electrosurgi- disassembled to facilitate manual cleaning, an
cal post to the tip of the instrument where the ultrasonic cleaning system may be c ontraindicated
Care and Handling of Laparoscopic Instrumentations 17
due to the small joints and jaws. Nevertheless, for lens adhesive. For sterilization, steam, liquid
effective sterilization to take place, surgical immersion, or plasma are some of the steriliza-
instruments need to be clean and free from all tion modalities that can be used. Nevertheless,
bioburden. And meticulous cleaning should since the manufacturers are responsible for devel-
begin at the point of use and immediately after a oping instructions for a process, which will ren-
surgical procedure. der a properly cleaned instrument sterile while
To assist in the subsequent cleaning process, preserving its function, the instruments should be
laparoscopic instruments should be periodically sterilized according to the manufacturers’ written
wiped down with a wet sponge and flushed with instructions.
solutions during surgery to prevent bioburden
solidification. The instruments should also be
immersed in an enzymatic solution immediately Conclusion
following a procedure to initiate the decontami-
nation procedure. Items in these instruments that Proper care and handling of laparoscopic instru-
can be disassembled should be disassembled to mentation can help prevent malfunctions and
its smallest parts, and those with flush ports rapid deterioration, which in turn eliminates
should be flushed, before soaking and cleaning. costly repairs and replacements. Every member
For the cleaning process, a detergent with a neu- of the surgical team together with the reprocess-
tral pH of 7.0 is recommended and avoids using ing personnel must work collaboratively to
abrasives, such as steel wool, that could disrupt achieve this important goal, to ensure the deliv-
the surface of the instruments. Instead use appro- ery of the safest and highest quality of patient
priate cleaning tools, such as soft bristle brushes, care.
to adequately clean ports, lumens, serrations, ful-
crums, box locks, and crevices. Both the external
and internal surfaces of the instruments must be References
cleaned thoroughly if not, they cannot be steril-
ized. If available, automatic cleaning devices, 1. Zucker KA. Surgical laparoscopy. St Louis, Mo:
Quality Medical Publishing; 2001.
with port and lumen flusher systems, can be used 2. The SAGES manual. New York: Springer-Verlag;
to assist in completely cleaning the instruments. 1999.
Contradictory to telescopes and light cables, 3. Yazdani A, Krause H. Laparoscopic instrument insu-
which should not be routinely cleaned in an ultra- lation failure: the hidden hazard. J Minim Invasive
Gynecol. 2007;14(2):228–32.
sonic device (as the vibration may damage the 4. Alkatout I, Schollmeyer T, Hawaldar NA, et al.
tiny fiberoptic bundles), laparoscopic instruments Principles and safety measures of electrosurgery in
can be cleaned using an ultrasonic cleaner, where laparoscopy. JSLS. 2012;16(1):130–9.
appropriate. 5. Montero PN, Robinson TN, Weaver JS, et al.
Insulation failure in laparoscopic instruments. Surg
Following the cleaning process, the devices Endosc. 2010;24(2):462–5.
should be sterilized or high-level disinfected 6. Voyles CR, Tucker RD. Education and engineer-
using chemical agents. Glutaraldehyde is one of ing solutions for potential problems with lapa-
the most appropriate chemical high-level disin- roscopic monopolar electrosurgery. Am J Surg.
1992;164(1):57–62.
fectants for soaking laparoscopes and accessories
because they do not damage rubber, plastics, or
18 A. Lee-Ong and S. K. P. Kwan
Electrosurgery and Energy Devices
Energy Devices inside the cells then the kinetic energy gets con-
verted to thermal energy and the desired effect in
Energy and surgery have evolved together so the tissue is determined by the electrical proper-
closely that in the modern era, even thinking of ties of the equipment being used, type, shape,
doing surgery without energy has become nearly size, thickness of the tissues as well as the dura-
impossible. There are many types of energy tion of exposure.
devices available to be used today but to use them Electrosurgical unit (ESU) or electrosurgical
safely, the knowledge on the principles of surgi- generators (Figs. 1, 2, and 3) are an essential part
cal energy and safety is important. of modern-day surgery and nearly all operation
During electrosurgery, radiofrequency alter- theaters will include at least one of them. It con-
nating current is used to raise intra-cellular tem- verts alternating current with 50–60 Hz to a
perature to achieve vaporization or a combination radiofrequency output of around 500 KHz.
of desiccation and protein coagulation. And these During the use of ESU, the patient or the tissue is
effects of old electro surgery devices (Fig. 1) included in the circuit.
have been modified in various energy devices to Most ESUs (Figs. 1 and 2) have two types of
achieve the desired effects on the tissues such as outputs. Namely, they are “cut” and “coagula-
cutting, coagulation, sealing or approximation of tion.” Some of the ESUs have a combination of
tissue, or a combination of these in new electro- these two that is known as “blend.” “Cut” uses
surgery devices (Figs. 2 and 3). The electromag- low voltage and continuous output from the gen-
netic energy is first converted to kinetic energy erator which is characterized by continuous
waveform. “Coagulation” uses high voltage and
modulated and dampened output from the gener-
S. Malik (*) ator. “Blend” options use a combination of these
Allama Iqbal Medical College, Jinnah Hospital, settings at varying degrees to achieve the desired
Lahore, Pakistan effect on tissues [1] (Fig. 3). The ESU output will
F. Khairi travel through one electrode and enter the patient
General Surgery Services, Alexandra Hospital, or the tissues and need to return back to the ESU
Queenstown, Singapore
through a second electrode to complete the
S. Wijerathne circuit.
General Surgery Services, Alexandra Hospital,
Queenstown, Singapore
General Surgery and Minimally Invasive Surgery,
Department of Surgery, National University Health
System, Kent Ridge, Singapore
https://doi.org/10.1007/978-981-19-3755-2_4
20 S. Malik et al.
Monopolar Systems
In Monopolar instruments, the surface area of the

active electrode is significantly smaller compared
to the dispersive electrode in order to achieve the
desired effect on the tissues and to prevent injury
to the patient at the dispersive electrode end.
Therefore, during Monopolar systems, the entire
Fig. 1 Old solid state electrosurgical unit patient becomes part of the circuit. The routine
handheld monopolar instrument, Laparoscopic
monopolar instrument with hook, and Multi-tined
radiofrequency ablation instrument are examples
for monopolar systems (Figs. 4, 5, and 6).
During the use of monopolar systems, the active
electrode can be held a few millimeters away from
the tissue and by using high voltage output from the
generator a tissue effect called Fulguration can be
achieved. During this process, the high voltage
allows ionization of the media in the gap between
the electrode and tissue and causes superficial coag-
ulation and carbonization of tissues. A similar prin-
ciple is used during the Argon beam coagulator that
is used to achieve hemostasis without tissue contact.
Argon gas is used as the medium between the tissue
and the electrode, in this case, to facilitate arcing of
the current [1].
Fig. 2 Ethicon endo-surgery unit-harmonic
Fig. 4 Monopolar hand control diathermy
Fig. 5 Monopolar diathermy tip
Fig. 3 Modern valleylab FT 10 energy platform Fig. 6 Laparoscopic monopolar L-hook

Electrosurgery and Energy Devices 21
The other mechanism of injury is due to cur-

rent diversion. All our active electrodes come
with insulation except at its tip to protect the rest
of the instrument and the surgeon and to make the
surface area of the active electrode smaller to
ensure desired tissue effect. This insulation can
get damaged due to repeated usage and this can
result in diversion of current from the noninsu-
Fig. 7 Bipolar diathermy tip lated areas to adjacent tissues resulting in injuries
and this is called insulation failure.
Direct coupling can happen if an active elec-
Bipolar Systems trode is activated while another metal instrument
is in contact with it, resulting in injury to the tis-
In bipolar systems, both electrodes are incorpo- sues that the metal instrument touches. Capacitive
rated into the instrument and are at the tissue coupling happens when the circuit is not com-
level. The output from the ESU only goes through pleted when an active electrode is activated with
the tissues that lie between the two electrodes of high voltage output and when using longer instru-
the instrument. Bipolar forceps used in both open ments with thin insulation in narrow metal tro-
and laparoscopic surgery are examples of bipolar cars. There is a buildup of charge between two
systems (Fig. 7). conductors that are separated by the insulator that
can get discharged to adjacent tissues causing
injury. Injury can also happen if the insulation of
Mechanisms of Electrosurgical the wires in the circuit is damaged causing diver-
Injury sion of the current [2].
It is important to understand the principles of

electrosurgery for early identification and pre- Advanced Bipolar Devices
vention of electrosurgical injury. In relation to the
ESU, these injuries can happen anywhere The flow of current in a bipolar device is only
between the active electrode and the dispersive through the tissue between the two electrodes
electrodes include the sites of the two therefore the tissue effect can be precisely con-
electrodes. trolled to minimize the lateral thermal injury. In
At the active electrode site, injuries can hap- advanced bipolar devices, the ESU is capable of
pen because of inadvertent activation of the elec- recognizing the impedance in the tissue grasped
trode or as a result of direct extension of the between the two electrodes or jaws of an instru-
desired tissue effect beyond the targeted area ment while the energy is delivered, and these
which is also known as the lateral thermal spread ESU microprocessors (Fig. 8) are able to then
or damage. adjust the amount of energy delivered based on
Dispersive electrode should be applied on a the impedance. And this process allows for ade-
clean and dry area of skin and this area should not quate tissue sealing while minimizing collateral
have excess hair that would result in entrapment tissue damage.
of air and also should be away from any metal Most modern advanced bipolar devices are
implants or bony prominences to avoid any ther- capable of sealing vessels up to 7 mm in diame-
mal injury. Partial detachment of the dispersive ter. However, the advanced bipolar devices use a
electrode can also result in thermal burns but the mechanical blade hidden within the jaws to cut
new ESU has built-in safety systems to detect the sealed tissue once the sealing is complete.
adequate contact between the dispersive elec- LigaSure™ (Medtronic, USA) and ENSEAL
trode and the application site of the patient. (Ethicon Endo-Surgery, USA) are some of the
22 S. Malik et al.
Fig. 10 Ligasure energy device tip insulation

Fig. 8 Laparoscopic advanced ESU bipolar micro bisect
physiologic blood pressure and they achieved

vessel seals within 8 s [4–10].
Ultrasonic Energy Devices
Ultrasonic energy device systems convert electri-

cal energy into mechanical energy. And these
systems use frequencies between 23 and 55 kHz.
The tissue effects of these devices include
mechanical cutting, desiccation, protein coagula-
Fig. 9 Laparoscopic advanced bipolar-Ligasure device tion, cavitation, or a combination of these.
These devices have an ultrasonic transducer
usually located in the handle and it is composed of
examples of advanced bipolar energy devices a stack of piezoelectrodes positioned between
that are currently available. Lamberton et al. [3] metal cylinders. Once the transducer is activated
compared three of the 5 mm bipolar (Ligasure then the piezoelectrodes get excited and vibrate
V, Gyrus PK, and Enseal) and an Ultrasonic the cylinders to an ultra-high frequency which
energy device in a bovine model to check for then linearly oscillates. And a metal blade or jaw
burst pressure, vessel sealing time, and mea- that is attached to this then oscillates in a linear
surements of lateral thermal spread. They found fashion to achieve the tissue effects [11]. The
that the Ligasure device (Figs. 9 and 10) attained amount of mechanical energy applied to tissue per
consistent seals with burst pressure above unit time is adjusted by varying the length of
150 mmHg for a majority (80%) of repeated excursion of the blade or jaw of the device.
applications while all other devices performed Usually, the range of excursions can be adjusted
at 50 %. The time needed for vessel sealing was between 50 and 100 μm. Based on the excursion
also shortest for Ligasure and longest for range; two settings of function are offered in these
EnSeal. The maximal lateral tissue temperature instruments. “Max” setting is offered at the maxi-
which was measured by a needle thermistor mum excursion where rapid cutting of tissue
placed 2 mm from the edge of the instrument occurs with less thermal spread, but this option has
showed that the ultrasonic energy device had the minimal hemostasis capability. The “Min” setting
lowest recorded. is where excursion is minimum which results in
In most other studies comparing similar less efficient cutting and a greater degree of col-
instruments, the burst pressures were well above lateral thermal damage and better hemostasis.
Electrosurgery and Energy Devices 23
Fig. 11 Laparoscopic advanced bipolar—Harmonic

device Fig. 12 Laparoscopic advanced bipolar—Thunderbeat
device
HARMONIC scalpel (Ethicon Endo-Surgery,

USA) and Sonicision™ (Medtronic, USA) are
examples of ultrasonic energy devices that are
currently available. Sonicision™ (Medtronic,
USA) is a cordless ultrasonic device that gives
more freedom and maneuverability to the sur-
geon. HARMONIC ACE® + 7 Shears (Ethicon
Endo-Surgery, USA) is the newest version of the
HARMONIC scalpel available (Fig. 11).
These are 5 mm instruments and have straight Fig. 13 Thunderbeat tip insulation
or curved tip configurations. Blade temperatures
can go up to 105 °C and the lateral thermal spread However, heat production that is comparable
can be up to 3 mm. Average arterial burst pres- to conventional ultrasonic scissors should be
sures ranged from 204 mm Hg to 1071 mm Hg minded for clinical use [17].
while average burst failure rates were 8–39%
[12–16].
Newer surgical energy devices like References
THUNDERBEAT® (Olympus, Japan) have
incorporated both advanced bipolar and ultra- 1. Munro MG. Fundamentals of electrosurgery part
I: principles of radiofrequency energy for surgery.
sonic systems and have shown advantages in In: Feldman LS, Fuchshuber PR, Jones DB, editors.
achieving faster cutting speeds thereby reducing The SAGES manual on the fundamental use of surgi-
operation time, reliable 7 mm vessel sealing, pre- cal energy (FUSE). New York, NY: Springer; 2012.
cise dissection with fine jaw design, availability p. 15–60.
2. Brunt LM. Fundamentals of electrosurgery part
of bipolar energy for hemostasis without cutting, II: thermal injury mechanisms and prevention. In:
minimal thermal spread, fewer instrument Feldman LS, Fuchshuber PR, Jones DB, editors.
exchanges and reduced smoke generation that The SAGES manual on the fundamental use of sur-
helps to maintain visibility. gical energy (FUSE). New YorkNY: Springer; 2012.
p. 15–60.
The ultrasonic and bipolar technique of the 3. Lamberton GR, Hsi RS, Jin DH, et al. Prospective
THUNDERBEAT® (Olympus, Japan) (Figs. 12 comparison of four laparoscopic vessel ligation
and 13) has the potential to surpass the dissection devices. J Endourol. 2008;22:2307–12.
speed of ultrasonic devices with the sealing effi- 4. Person B, Vivas DA, Ruiz D, Talcott M, Coad JE,
Wexner SD. Comparison of four energy-based
cacy of bipolar clamps.
24 S. Malik et al.
v ascular sealing and cutting instruments: a porcine 11. Bittner JG IV, Varela JE, Herron D. Ultrasonic energy
model. Surg Endosc. 2008;22:534–8. systems. In: Feldman LS, Fuchshuber PR, Jones DB,
5. Newcomb WL, Hope WW, Schmeizer TM, et al. editors. The SAGES manual on the fundamental use
Comparison of blood vessel sealing among new of surgical energy (FUSE). New York, NY: Springer;
electrosurgical and ultrasonic devices. Surg Endosc. 2012. p. 123–32.
2009;23:90–6. 12. Clements RH, Paiepu R. In vivo comparison of the
6. Sutton PA, Awad S, Perkins AC, Lobo DN. Comparison coagulation capability of Sono Surg and harmonic
of lateral thermal spread using monopolar and bipolar ace on 4 mm and 5 mm arteries. Surg Endosc.
diathermy, the harmonic scalpel and the ligasure. Br J 2007;21:2203–6.
Surg. 2010;97:428–33. 13. Gandsas A, Adrales GL. Energy sources. In: Talamini
7. Targarona EM, Balague C, Marin J, et al. Energy MA, editor. Advanced therapy in minimally invasive
sources of laparoscopic colectomy: a prospective ran- surgery. Lewiston, NY: BC Decker; 2006. p. 3–9.
domized comparison of conventional electrosurgery, 14. Hruby GW, Marruffo FC, Durak E, et al. Evaluation
bipolar compter-controlled electrosurgery and ultra- of surgical energy devices for vessel sealing and
sonic dissection. Operative outcome and costs analy- peripheral energy spread in a porcine model. J Urol.
sis. Surg Innov. 2005;12(4):339–44. 2007;178:2689–93.
8. Levy B, Emery L. Randomized trial of suture versus 15. Kim FJ, Chammas MF Jr, Gewehr E, et al. Temperature
electrosurgical bipolar vessel sealing in vaginal hys- safety profile of laparoscopic devices: harmonic ACE
terectomy. Obstet Gynecol. 2003;102(1):147–51. (ACE), Ligasure V (LV), and plasma trisector (PT).
9. Macario A, Dexter F, Sypal J, Cosgriff N, Heniford Surg Endosc. 2008;22:1464–9.
BT. Operative time and other outcomes of the elec- 16. Lamberton GR, His RS, Jin DH, Lindler TU, Jellison
trothermal bipolar vessel sealing system (LigaSure) FC, Baldwin DD. Prospective comparison of four
versus other methods for surgical hemostasis: a meta- laparoscopic vessel ligation devices. J Endourol.
analysis. Surg Innov. 2008;15(4):284–91. 2008;22:2307–12.
10. Song C, Tang B, Campbell PA, Cuschieri A. Thermal 17. Seehofer D, Mogl M, Boas-Knoop S, et al. Safety
spread and heat absorbance differences between open and efficacy of new integrated bipolar and ultra-
and laparoscopic surgeries during energized dissec- sonic scissors compared to conventional laparoscopic
tions by electrosurgical instruments. Surg Endosc. 5-mm sealing and cutting instruments. Surg Endosc.
2009;23(11):2480–7. 2012;26(9):2541–9.
Endo-Laparoscopic Suturing
and Knotting: Tips and Tricks
Tuhin Shah
Introduction dures contribute to the adverse performance of

fine movements in this skill. Thus, endo-
During General Surgery training, suturing and laparoscopic suturing is associated with a longer
knot-tying for open surgery is relatively easy and and steeper learning curve compared to that in
one of the initial skills to be acquired and mas- open surgery [1].
tered. In contrast, similar skills in Minimally Aside from the knot-tying skill and the type of
Invasive Surgery (MIS) are more challenging to knot thrown, the braiding, the material, and the
acquire and take an eternity to achieve profi- size of the suture used influence the security of
ciency. Competence and confidence in laparo- the knot. The monofilament sutures have a risk of
scopic suturing allow the surgeon to venture into slippage and are less pliable compared to braided
complex procedures and is an indispensable skill sutures. The hydrophilic material (catgut, Dacron,
for dealing with intraoperative events. polyglactin, and lactomer) swells on contact with
In open surgery, one has the advantage of bin- water and theoretically results in a more secure or
ocular vision providing depth perception; how- tighter properly thrown knot. Among sutures of
ever, in MIS, the surgeon encounters various similar material, the larger sized will allow more
hindrances: indirect visualization, loss of force to be applied before breaking thus the tight-
freedom of movement, fixed-port positions, and ness of a knot using 2–0 suture is double that of
limited working space. These eliminate three- one with 3–0 suture.
dimensional view (unless using a 3D video sys- As a teaching module, there are various
tem), restriction of instrument movements and options to choose from and Peyton’s four-step
movement about the target, and restricted move- approach seems the most attractive. It can be
ment within the workspace. Ergonomics contrib- used for a better teaching-learning experience. It
utes to setting a comfortable and efficient posture includes:
for executing the skill; cognizance of elements
like azimuth angle, elevation angle, manipulation 1. Demonstration
angle, and triangulation are beneficial. Effect of 2. Deconstruction
stress, pressure, and fatigue during MIS proce- 3. Comprehension
4. Performance
T. Shah (*)
Department of Surgery, Manmohan Memorial It is practice and repetition which helps
Medical College, Kathmandu, Nepal acquire the skill and bring finesse to the applica-
MISC Department of Surgery, National University tion of the trained knowledge in the operating
Hospital, Kent Ridge, Singapore room [2]. Hospitals and medical universities
https://doi.org/10.1007/978-981-19-3755-2_5
26 T. Shah
need to modify their training curricula to include ver. If the angle of the port is not in the same
the basic and advanced suture training courses, direction as the region of surgery then it will
skills lab, simulators, and personal video-box cause the surgeon to work against the abdominal
assembly and self-training along with regular wall, especially if it is an obese patient.
conduction of outreach programs to further Position of the Surgeon. The camera should
spread the basic skill, knowledge, and be positioned between the two instrument ports;
awareness. this setup matches the normal relationship
between the eyes and two hands as in open sur-
gery (Fig. 1a). The surgeon should be in a relaxed
Equipment and Instruments stance with the table height matched adequately
so that he/she does not have to slouch or strain.
• Laparoscope camera with monitor display and The monitor should also be placed at an eye level
light source, to prevent neck strain, this is especially important
• Laparoscopic needle driver set, in lengthy surgeries and high-volume centers
• Laparoscopic grasper and forceps laparo- (Fig. 1b).
scopic scissors, Eye-Hand Coordination. Movements made
• Knot pusher for extracorporeal suturing, during laparoscopic surgery should be slow and
• Trocars–5, 10, 12 mm ports—metallic or steady compared to open surgery and the move-
plastic. ments have to be limited to the field of vision.
• Sutures. This is especially true when one is dealing with
• Mayo scissors. sutures and instruments like scissors and cautery.
• Artery forceps. Eliminating unnecessary movements and taking
• Measuring tape. choreographed actions during the procedure will
help the surgeon and the OR team for more
There are different types of needle holders focused and productive output. A formal training
available. Generally, needle holders have jaws course can help to learn these ergonomic skills
that are more powerful and sturdier than other for better productivity. A high level of concentra-
laparoscopic forceps and graspers. They have tion is integral to perform even simple needle-
serrations for better needle grip, a catch for lock- driving maneuvers.
ing and unlocking, and they can be straight or
curved and fits in the 5 mm trocars.
Needle Tip and Suture Materials
General Principles Different types of needles:
Setting the Scene. It is a crucial and important • Straight needle,

step in suturing. It should be like an orchestra and • Ski needle, and
the surgeon needs to put himself in the best ergo- • curved needle.
nomically available condition concerning posi-
tion, angle, height, choice and placement of The straight needle is easier to insert and
instrumentation, light source, choice of suture, remove from the trocars but is not used fre-
and type of knotting among others. A good cam- quently. Also, the different angles to be achieved
era with adequate lighting and a high-definition by the straight needle is difficult to achieve
display can make all the difference that is required comparatively. Ski needles are easier to go
for a smooth surgery. through the trocars on the comparison.
The thickness of the abdominal wall, the posi- Straightening the curved needle using the nee-
tion, and the angle of the port placement are vital. dle drivers/forceps before removal is another tip
Too far or too near will make it difficult to maneu- for easy extraction.
Endo-Laparoscopic Suturing and Knotting: Tips and Tricks 27
a b
Fig. 1 (a) Camera position and (b) Surgeon’s stance
A needle tip with taper cut penetrates tissues

more readily than blunt tip needles hence lesser
trauma. Needle size of 2–0 and 3–0 is optimal for
laparoscopic use as it allows easy passage and
removal in the trocars.
While using just the one 10 mm camera port
with a combination of 5 mm ports during surgery,
Square knot Ligature knot
inserting a needle can be done through the 10 mm
camera trocar and after suturing, it can be extracted
through the 5 mm trocar after straightening the
needle. Before inserting the suture, the direction of
the 10 mm trocar should be static after confirming
the visual field of the camera to a safe area so that
even though it is a blind insertion of the needle, it Double knot Mayo’s knot
will land safely in the operative field.
Colored sutures are preferred over colorless
sutures for better visibility. Traditionally divided
into two groups: absorbable and nonabsorbable;
braided and monofilament. A suture that swells in
contact with water increases its capacity of tying
and tightening and can be considered safer, Granny knot
Surgeon’s knot
whereas monofilament sutures have a higher risk
of slippage when compared to braided sutures.
The tightness of a suture knot of a 2/0 thread is Fig. 2 Types of knot
double than a 3/0 thread (Fig. 2).
Insertion and Retrieval of the Needle. It
should be done only under direct laparoscopic 2–3 cm behind the needle while transferring it in
vision. The suture thread should be grasped some or out through the trocars.
28 T. Shah
While extracting the needle through metal tro- The ideal length of a suture for intracorporeal
cars, there is a chance of the needle to get caught suturing is 10 cm; this length makes the knot-
in the diaphragm of the trocar on its exit, which tying maneuver easier. For a continuous suture,
can then snap and/or break the needle. The dia- the thread should be about 15 cm long, this allows
phragm should be kept open manually while the surgeon a way to accomplish the final knot
extracting the needle. Some may prefer to with enough suture thread in hand.
straighten the needle for easy extraction.
Loading the Needle: Loading depends upon Techniques of Knot Tying
the conditions and also the proximity or other- In the intracorporeal technique, the knot is made
wise of a smooth serosal surface. There are two inside the abdominal cavity using two instru-
processes for loading the needle. ments, these can be two needle holders or
forceps.
• The dangling pirouette technique. In the extracorporeal technique, the knot is
• The deposit—pick-up technique. made completely outside the abdominal cavity
and then it is pushed inside the abdomen with a
This can be achieved in three ways: knot pusher.
1. First, the thread around 2–3 cm from the nee- Intracorporeal Knot Tying
dle is held using the dominant hand. Next The advantage of intracorporeal suturing [3] are:
using the nondominant hand grasp the needle
about one-third from the tip. Now the domi- • The amount of suture that is being drawn
nant hand is repositioned at two-third from through the tissue is limited thus reducing
the needle tip—the sweet spot. trauma and cut through, and,
2. Lightly grasp the needle at the distal one-third • The suture material that is being used can be
with the nondominant hand. With the domi- finer.
nant hand gently pull the thread—2–3 cm
from the needle—towards you or away from Hence, delicate structures like bile ducts and
you so that angle from the needle can be mod- intestines can be sutured using this technique.
ified. Now with the dominant hand reposition Before throwing the knots, it should be
the grip on the needle at the sweet spot. checked that the distal end of the suture is no lon-
3. After laying the suture on a safe surface, using ger than 2–3 cm and in vision so it can be grasped
the dominant handgrip the needle lightly at easily. The number of throws depends on the
the sweet spot and gently brush with the con- suture used.
cavity of the needle on the tissue forward for
backward within the 3 o’clock direction till
the correct position is attained. The nondomi- Roser Technique
nant hand can be used to assist as well.
Hold the needle with its concavity bent down-
Loading the needle during laparoscopy is an wards with the nondominant hand. In this way,
important skill to master. It should be learned by the curved and rigid structure of the needle allows
all surgeons who are interested in pursuing the the forming of the “C-loop” for the needle holder
minimally invasive approach. Suturing and nee- of the dominant hand to twirl on it. This makes it
dle handling are crucial. A trainee has to under- easy to perform the spirals around the needle
stand and learn how the needle driver works holder before grasping the distal end of the
laparoscopically and how to move the needle and suture.
the needle drivers effectively through the tissues To complete the knot, the needle is dropped in
without causing unnecessary trauma. a safe place and the nondominant hand grasps the
thread close to the knot to tighten it by moving middle. Then the needle is pulled through this
the hands in opposite directions. Repositioning newly formed loop, to stabilize the suture and
of the instruments to hold the suture closer to the continue for continuous suturing.
knot should be done to stay within the visual field Or a preformed loop can be made for this pur-
to avoid injury to adjacent structures. pose (described below).
The first knot placed is a double spiral/throw.
This is followed by again holding the needle with
concavity down and repeating the above process Extracorporeal Knot Tying
to throw single knots and tightening it.
It is important to learn at least one knotting tech-
nique and use it when required. The advantage of
Szabo Technique extracorporeal suturing is the ability to use famil-
iar knotting as in open surgeries which can then
The C-loop can also be made with the suture be secured using a knot pusher. However, it is not
instead of the needle concavity around which the preferred for suturing delicate structures.
twirls can be made for the knots. The C-loop can Extracorporeal slip knots can only be used for
be made by just pulling the suture slightly for- free-ending structures, like the appendix, perito-
ward or outward with the dominant hand while neal tear in TEP, and for ligating transected duct/
the distal end is being held by the dominant hand vessel.
before throwing the spirals. It is of two types:
1. Extracorporeal slip knot

Alternative Method 2. Extracorporeal surgeon’s knot
Grasping the suture thread 1/2 cm distal to the There are a lot of methods to make a pre-
needle with the dominant hand, then one has just formed loop for a slip knot, here a couple of them
to rotate the instrument to wind the thread around are described. The length of the suture has to be
the needle holder. Then forceps are used to grasp 45 cm for the creation of the loop for the slip
the needle end with the other hand while the knot.
dominant hand catches the distal end of the
suture. The knot is accomplished by pulling on • Tayside knot: Perform 3–4 windings between
both ends. the distal and the medial end of the suture, this
results in a loop through which the distal
suture end is threaded. This generates a new
Suture Designs loop through which the distal end of the suture
is passed. By pulling on the distal suture end
A thread furnished with absorbable terminal clips the knot is tightened generating a slipknot.
for anchoring. The clip anchored to the suture • The formula for making the Roeder’s knot is
thread end functions as an initial knot and a sec- (1:3:1) “one hitch, three winds, and one locking
ond clip can be applied at the proximal end after hitch”. First, a loop is made around a post and
suturing is complete to avoid the need for tying then a simple knot is made. With the shorter
knots. end, three winds are made around both posts
Another is barbed sutures which prevent it and are secured with the last half hitch. The
from slipping back through the tissues and avoids knot is then tightened and checked for sliding.
the need to make knots to secure it in place. The excess length of the string is trimmed.
When using a braided thread, a preformed • Also, there are commercially available
loop can be created simply by piercing the distal Endoloops which can be used, but with added
end of the suture with the needle, exactly at its cost.
30 T. Shah
Once this preformed loop/Endoloop is inside There are other options available for stitching
the abdominal cavity, the structure to be ligated is apart from the sutures. They are:
placed through the loop and the loop is tightened
with the knot pusher, and the excess suture cut. • Liga clips and Hemolok clips: They can be
For structures which are not blind-ended (e.g., used for clipping small and medium-sized
vessels or cystic duct) the following methods can vessels/ducts and replaces the need to place
be used. sutures and saves time.
• However, they require specific instruments for
• A suture thread is passed under the structure their deployment.
and both ends are taken out. A loop as • Tackers: They are absorbable or nonabsorb-
described above is tied and is then pushed able. They are used to fix the mesh in situ and
down with knot pusher and tightened. for the closure of the peritoneum.
• Also instead an extracorporeal surgeon’s knot • But since they are driven into tissues they are
can be made and pushed in followed by square associated with some pain postoperatively,
knots to secure. This can be used in all can lead to bleeding if it punctures vessels and
instances of laparoscopic suturing however if used in the path of the nerves then chronic
due to the long length of suture chances of cut pain.
through and inadvertent injury is higher. For • Hence should be used with good anatomical
extracorporeal suturing, the suture length has knowledge.
to be at least 75 cm (Fig. 3). • Stapling devices: They can also be used lapa-
• The granny knot and square knot can be con- roscopically with good outcomes. They can be
verted into a slip knot by applying tension on used for gastrointestinal resection/anastomo-
the suture ends as demonstrated. And then this sis and bile duct resection. Stapling devices
can be slipped down using graspers/knot borrow the same principle as used in open sur-
pusher to tighten the knot. This is easier when gery, but are technically more demanding,
using monofilament sutures. with the limited space available and different
Fig. 3 Slip and square knot

angles to fire the staples at. They are available ing morbidity, increasing the patient recovery
as straight and circular devices for anasto- period, length of stay, and more importantly
motic purposes. The circular device is more decreasing the surgeons productive and func-
complex to use. It is used for endo-laparoscopic tional output during the operation. To improve on
anastomosis of the esophagus, rectum, and this, a trainee can record and analyze their tech-
gastric cuff in bypass surgery. For intra- niques from simulators/skills lab and obtain feed-
abdominal insertion of laparoscopic stapling back from colleagues and experienced trainers to
devices, a 12 mm port is required. perfect them.
• Tissue Glue: Tissue adhesives are also being Despite modern technology, a laparoscopic
used in certain conditions like for fixation of surgeon still needs to learn and perform the tradi-
hernia mesh in TEP and TAPP. The advantage tional suturing and knotting techniques as one
being that it does not cause chronic pain and may never know when and where it will be
can be used on and near the triangle of pain for required and essential. Skills lab and training
better fixation when compared to tackers. It is courses are important for such teaching-learning
also being used in combination with other programs and should be made essential for all
techniques as an aid that provides a hemo- teaching institutes as a part of their curricula.
static or hydrostatic seal.
References
Conclusion
1. Chew S, Wattiez A, Chomicki L, editors. Basic laparo-
scopic techniques and advanced endoscopic suturing:
Practice and repetition are required to master any a practical guidebook. World Scientific; 2000.
skill in surgery and especially in laparoscopy and 2. Liceaga A, Fernandes LF, Romeo A, Gagstatter
laparoscopic suturing and knotting. F. Romeo's gladiator rule: knots, stitches and knot
Performing a suture and a knot in laparoscopy tying techniques a tutorial based on a few simple rules;
new concepts to teach suturing techniques in laparo-
without the necessary experience and practice scopic surgery. Tuttlingen: Endo-Press; 2013.
not only increases the operative time but it also 3. Croce E, Olmi S. Intracorporeal knot-tying and sutur-
indirectly increases the hospital costs by increasing techniques in laparoscopic surgery: technical
ing the consumption of medical supplies, increas- details. JSLS. 2000;4(1):17–22.
Ergonomics: An Overlooked
Training
Tuhin Shah
Introduction Human errors have been classified in the fol-

lowing categories:
Ergonomics plays an important role in the work
environment however it does not receive due (a) Mistakes: The surgeon makes an error
attention. Many are unaware of the terminology because of an incorrect interpretation of the
much less the specifics it contributes to an effi- anatomy or situation, e.g., mistaking the
cient, safe, and productive workplace. CBD for the cystic duct and dividing it.
The term “ergonomics” is derived from the (b) Slips: The surgeon makes the right decision
Greek words “ergon” meaning work and “nomos” but carries out the wrong action (e.g., presses
meaning natural laws or arrangement. Ergonomics the “cut” instead of the “coagulation” pedal
can be defined as the scientific study of people at on the electrocautery).
work, in terms of equipment design, workplace (c) Lapses: The surgeon neglects to perform a pro-
layout, working environment, safety, productiv- cedure or a specific step in a procedure (e.g.,
ity, and training. This depends on many factors forgets to check the integrity of a colonic anas-
including anatomy, physiology, psychology, and tomosis using air insufflation before closing).
engineering. Simply, it can be said that ergonom-
ics is the science of best suiting the worker to his There are various factors to consider in the OR
workspace. during laparoscopic surgery which can ease the
Ergonomics may also be referred to as the access and make working in such a setting pro-
human factor in certain places. Considering that ductive and well-organized. Though they may
ergonomics involved in the operative room is seem insignificant initially however incorporat-
vital for increasing efficiency and minimizing the ing them into the daily workplace will reap ben-
fatigue of the surgical team. Ergonomics is essen- efits over time [1–3].
tial in centers with high volume, where long con-
tinuous working time and repetitive actions are
the norms. Straight Line Principle
The visual monitor from the surgery should be

T. Shah (*)
adjusted before the surgery to avoid undesirable
Department of Surgery, Manmohan Memorial postures or neck-straining for a prolonged time.
Medical College, Kathmandu, Nepal The monitor should be adjusted during the
MISC Department of Surgery, National University surgery if required depending on the surgical
Hospital, Kent Ridge, Singapore field to keep the visual plane in a straight line.
https://doi.org/10.1007/978-981-19-3755-2_6
34 T. Shah
Fig. 2 Triangulation: This is important to avoid fighting

Fig. 1 Straight line principle: the surgeon, the operative and clashing of instruments and easy tiring
field, and the monitor should be in a straight line for maxi-
mum efficiency
In the horizontal plane, the monitor should be

straight ahead of the surgeon and in line with the
surgical field along with the forearm–instrument
motor axis. Additional monitors should be used if
the assistants and nurses are standing in a differ-
ent or opposite to the operating surgeon/operative
field to avoid fatigue for the assistants (Fig. 1).
Triangulation
The placement of ports by surgeons is based on

individual preference and experience. To facili-
tate easy instrument handling and to have a good
visualization, trocars should be placed in a trian-
gular manner. This is known as triangulation
(Fig. 2). The target organ should be about 15 cm
from the camera port. The remaining trocars are Fig. 3 Baseball diamond concept
placed similarly in an arc at 5–7 cm on either side
of the camera port. More ports can be placed in Manipulation Angle
the same arc with a gap between instruments to
prevent clashing. This allows the instruments to The manipulation angle is the angle formed between
work freely at a 60–90° angle with no clashing two working instruments (active and assisting). The
and fighting with the other instruments (Fig. 3). ideal manipulation angle is between 45–60°
When the endo-laparoscope is situated lateral (Fig. 4); a smaller or larger angle is associated with
to the working instruments, it is called “sector- increased maneuvering difficulty and poorer perfor-
ization.” This makes it more challenging to work mance. A narrow angle will cause clashing and
with all lateral ports as the vision is also lateral- fighting between instruments, while a larger angle
ized, but with practice and use of an angled lapa- will result in the need to abduct the arms more lead-
roscope, it can be adapted. ing to straining of the shoulder muscles.
Ergonomics: An Overlooked Training 35
Azimuth Angle
The azimuth angle is the angle between the

instrument and the optical axis of the endoscope.
The ideal azimuth angle for easy and maximum
productivity ranges from 30–45°.
Surgeons’ Body Posture
The ideal position for the laparoscopic surgeon is

a relaxed stance with the arms slightly abducted,
retroverted, and rotated inward at the shoulder
level and the elbow should be bent at a 90–120°
angle and the neck slightly flexed with a down-
ward gaze. The operating table with clamps on the
Fig. 4 Ideal manipulation angle side for attachments can obstruct the surgeons/
assistants from standing in the desired position.
These should be organized so that they are at least
obstructive position and removed if unnecessary.
Position of Visual Display (Monitor)
The position of the monitor depends on the size

of the screen that is being used. However, ideally,
the monitor should be 90–200 cm away in the
straight line across from the surgeon in a gaze-
down view. This is easier to attain by the use of
ceiling booms which will help the movement of
the monitor in forward/backward as well as up/
down direction rather than on a trolley placed on
the ground as then the height cannot be adjusted.
Fig. 5 Manipulation, Elevation, and Azimuth angle It is also beneficial to occasionally relax the
shown in a patient. 1. Manipulation angle, 2. Azimuth body and mind by moving around, looking away
angle, 3. Elevation angle from the monitor, and letting go of the instruments.
In open surgery, the surgeon unconsciously takes
Elevation Angle these minibreaks but forgets during laparoscopic
operations which are usually more intense with the
The elevation angle is the angle between the surgeon/assistants in a more stationary position.
instrument and the horizontal plane. There is a
direct correlation between the manipulation and
elevation angles. They should be equal to each Gaze-Down View
other for maximum efficiency. For example, with
a manipulation angle of 60°, the corresponding The screen should be positioned lower than the sur-
optimal elevation angle, which yields the shortest geon’s eye level to avoid neck extension and strain-
execution time and optimal performance is also ing. The most comfortable viewing direction is
60° (Fig. 5). approximately 15° below the eye level to avoid the
36 T. Shah
scopic monitor. This allows surgeons to activate

the pedal without twisting their body or the leg.
Newer pedals with built-in footrest are preferable
as it prevents the surgeon from keeping the foot
hanging in the air.
Port Placement and Instruments
The ports should be placed such that the various

instruments do not clash with each other. Also
while the placement of the ports it should be
noted that the ports should lie slightly obliquely
pointed toward the target quadrant. This is of
importance especially in obese patients to avoid
working against the abdominal wall with a poorly
inserted trocar.
Instruments should be inserted such that at
least half of the instrument is inside the patient. If
less than half of the instrument is inserted inside
the abdominal wall then excessive motion at the
shoulder will be required, which is likely to
Fig. 6 Ideal surgeon stance, ideal monitor and table
fatigue the surgeon sooner. After the instruments
height during laparoscopy
have been inserted into the ports they should be
chin-up position. Viewing distance is dependent on roughly at, or slightly below, the level of the sur-
the monitor size. It should be far enough to avoid geon’s elbows.
straining on the eyes usually at 90–200 cm distance When it is necessary to continuously grasp tis-
(Fig. 6). sues it is recommended to use an instrument that
has a lock or ratchet mechanism that will main-
tain the force, also palming an instrument instead
Height of Operating Surface (Table) of using finger bows to hold it or using external
fixators help in such conditions.
The operating table must be adapted to the sur-
geon’s height and position. The table’s height
should be adjusted in such a way that laparo- Surgeons and Team Placement
scopic instrument handles are slightly below the
level of the surgeon’s elbows which should be The surgeon can stand on either side or between
flexed at a 90–120° angle. This is usually 0.8 the legs of the patient depending on the easy
times the elbow height of the surgeon. access, comfort, and preference to maintain a
straight line principle. The assistant/nurse also
should stand such that the view of the monitor
Foot Pedal Location is not obliquely placed or blocked by another.
It is advisable to use multiple monitors to avoid
Pedals should be placed near the surgeon’s foot visual obstruction, especially on ceiling booms
and lined in the same direction as the instru- to be height adjustable depending on the OR
ments, toward the target quadrant and laparo- team.
Ergonomics: An Overlooked Training 37
Ambient Room Lighting torsion of the scrubbed nurse/assistant while

passing the instruments.
The OR should have the capacity to be dimmed
during laparoscopic surgery to avoid glare and
visual discomfort to the surgeon and the operat- Conclusion
ing team. However, it should not be too dark for
the assistants/scrub nurses/circulating nurses to With the increasing use of technology in the field
pass instruments or hamper movement in the OR. of laparoscopy, there are newer physical and men-
tal challenges. This warrants more attention to pro-
mote better ergonomics in laparoscopy by
Scrubs and Footwear encouraging the medical field to promote the prin-
ciples of ergonomics and to conduct training using
The scrubs used should not be oversized or small these ergonomic guidelines and also by promoting
to cause a restriction in the movement. The scrubs research in this field for a better understanding.
and the footwear should be light and well venti- These matters though they seem minor and
lated. The scrubs should not have too many pock- insignificant however, in the long run, they can
ets or items placed in them to drag down the lead to medical problems as well as decrease the
scrubs to cause discomfort. efficiency of the surgeon/OR team and increase
the operative time thus indirectly increasing OR
cost, patient recovery time, and admission period.
echnical Advancement and Clutter
T The most common reason for the inability of
of Equipment ergonomics to be applied optimally is lack of
awareness, communication gap, and lack of
With the use of laparoscopy, there are extra knowledge about associated medical problems. It
instruments and equipment that are required, is advised to have an active member/team who can
these take up valuable space hence a laparoscopic communicate the properties and benefits of ergo-
OR should be bigger. Also, since all the equip- nomics to the rest of the OR for its implementation
ment are numerous and bulkier therefore they and smooth movement throughout the OR.
should be circulated using trolleys to avoid
fatigue and musculoskeletal strain. The tubes and
scopes should be organized on and off the operat- References
ing table so that they do not cross and get tangled.
1. Mishra RK. Textbook of practical laparoscopic sur-
Usually, each team has their method to achieve gery. 2nd ed. New Delhi: Jaypee; 2009.
this and is usually perfected over time. Also, the 2. Berguer R. Ergonomics in laparoscopic surgery; 2006.
assistant/nurse can help during the operation to https://doi.org/10.1007/0-387-29050-8_60.
maintain order. The Mayo’s trolley should be 3. Sánchez-Margallo FM, Sánchez-Margallo
JA. Ergonomics in laparoscopic surgery. 2017; https://
placed such that it avoids excessive turning and doi.org/10.5772/66170.
Hemostasis in Laparoscopic
Surgery
Introduction adjunct hemostasis (tissue adhesives and seal-

ants) methods [1]. We provide a broad overview
Hemostasis is the term that refers to the typical of these two available methods during laparo-
response of the vessel to injury by activation of scopic surgical intervention.
the blood clotting mechanism to limit bleeding. It
has been an essential goal in any surgery to main-
tain hemostasis by restricting the blood loss thus Mechanical Methods of Hemostasis
reducing the need for blood transfusion and its
complications. Hemostasis is more prudent dur- Direct Pressure
ing laparoscopic surgery where the intervention Direct pressure is often possibly the first maneu-
is performed through small incisions using the ver employed to achieve hemostasis in laparo-
camera and specialized instruments, as even scopic surgery. Direct application of blunt
minor bleeding may affect visualization, the laparoscopic equipment, e.g., a 5 mm blunt tip
safety and quality of the procedure, and patient atraumatic grasper to a bleeder point, temporarily
outcome. stops the blood loss through local tamponade [2].
In laparoscopy, surgeons can attain a blood- Direct pressure allows the surgeon time to ade-
less field with various available methods of quately visualize the area of interest and formu-
hemostasis which requires the timely and appro- late the next course of action for hemostasis.
priate use of technology. Having a sound under- Applying the direct pressure against a gauze wick
standing of each of the numerous forms of or sponge at the bleeding point, which is inserted
hemostasis will ensure proper usage and avoid through a 10 mm port can further enhance the
complications. As a general rule, there are two effect of this method (Fig. 1).
available methods for hemostasis during laparos- With regards to physiology, such maneuver ini-
copy, namely standard mechanical hemostasis tiates the process of hemostasis through platelet
(ligation, suturing, and electrocautery) and aggregation and fibrin clot formation. Furthermore,
it may well be all that is required to halt the bleed-
A. R. Yusoff (*) ing depending on the size of the blood vessels and
Department of Surgery, Universiti Teknologi MARA, the patient’s coagulation status [2].
Sungai Buloh, Selangor, Malaysia
D. Lomanto Electrosurgical Tools
Department of Surgery, NUS KTP Advanced Surgery
Training Centre and Minimally Invasive Surgical
Electrosurgical tools are often the principal
Centre, YLL School of Medicine, National University instrument for securing hemostasis after local
of Singapore, Kent Ridge, Singapore tamponade. This tool delivers an energy source
https://doi.org/10.1007/978-981-19-3755-2_7
40 A. R. Yusoff and D. Lomanto
trol of significant bleeding or larger vessels

and complications such as argon gas embo-
lism and pneumothorax have been reported
from its injudicious use.
• Advanced Bipolar System
The LigaSure™ vessel sealing system
(Valleylab, Boulder, CO) utilizes a form of
bipolar current that is locally modified through
a feedback control mechanism on the ESU. As
the resistance of the tissue changes during
desiccation, the generator adjusts the pulsed
Fig. 1 Using tonsil swab for hemostasis
energy accordingly. Therefore, a high current
with low voltages energy is used to melt the
from an electrosurgical unit (ESU) to the tissue collagen and elastin thus creating a seal with a
causing thermal destruction and consequently simultaneous hemostatic division of tissue.
hemostasis. The energy can be achieved either by The LigaSure™ device is recommended for
monopolar or bipolar electrocautery [2]. Details vessels sized <6 mm only [1].
of the physics of ESU, its principle and compli- • Ultrasonic Energy
cations are discussed in another chapter. A piezoelectric harmonic scalpel (Harmonic®,
Ethicon US, OH, USA) is a tool that simulta-
• Monopolar Electrocautery neously excises and coagulates tissue with
This form of electrosurgery involves current high-frequency ultrasound. A frequency of
from an active electrode, predominantly hook, 25 kHz induces mechanical vibration at the
grasping forceps, or scissors that are attached cellular level resulting in dissection and cavi-
to a monopolar generator, which passes tation as seen in cavitational ultrasonic aspira-
through the patient and returns through a large tor (CUSA Technologies, Salt Lake City, UT)
grounding plate. [1, 2]. At a higher ultrasound frequency of
• Bipolar Electrocautery >55 kHz, this piezoelectric ceramic element
In this form of electrosurgery, the active elec- expands and contracts rapidly thus generating
trode is intermittently opposed to the return frictional energy that causes a hidden moving
electrode (usually in a forceps-type arrange- blade to oscillate. This results in mechanical
ment). The electrical current passes between energy that seals blood vessels and transects
the electrodes to complete the circuit, and the tissues without passing the current to, or
flow of current beyond the surgical field is through the patient.
minimal. The bipolar application thus mini- The harmonic scalpel is known to cause less
mizes the risk of damage to nearby tissue. collateral damage, avoid carbonization of the tis-
• Argon Beam Coagulator sue, and reduces local thermal injury. It has been
Argon beam coagulator is a monopolar elec- used widely in laparoscopy for tissue dissection
trocautery instrument that uses an ionized, and control of local blood vessels. It has two
argon jet to complete the circuit between the modes of action; lower power causes slower tissue
active electrode and the target tissue to “blow- heating and more coagulation effect, while higher
off” the surgical field by surface proteins power setting causes rapid cutting but is relatively
denaturation and shallow eschar formation. It nonhemostatic. However, the use of the harmonic
is sufficient for minor capillary bleeding after scalpel is limited to vessels of <4 mm in diameter
dissection, especially that involves solid organ (Fig. 2). Newer generation device may allow seal-
parenchyma. It is however unsuitable for con- ing of up to <7 mm diameter [1, 2].
Hemostasis in Laparoscopic Surgery 41
however, as for suturing, it may not be handy in

laparoscopic surgery for many.
• Simple Ligature
Again both extracorporeal and intracorporeal
methods can be used to execute the ligature.
• Pretied Suture Loops
Ready-to-use pretied suture loops (Endo-
loops) may be particularly useful for sur-
geons unfamiliar with laparoscopic suturing.
Fig. 2 Application of endoscopic clip system for ligation
of cystic artery and use of ultrasonic energy device for
Its use however requires the division of a
transection of the artery bleeding vessel or vascular pedicle in order
to loop the vessel of interest hence its sub-
optimal choice where the vessels are still
Suturing intact.
Similar to open surgery, tissue approximation by
suturing will result in immediate hemostasis if ndoscopic Clip Systems
E
done correctly. Suturing can be achieved either An endoscopic clip is another method pre-
by extracorporeal or intracorporeal methods ferred by most surgeons to seal a blood ves-
depending on the surgeon’s preference or experi- sel. Both 5 and 10 mm reusable clips and
ence. Although suturing is the most basic in open appliers, as well as their disposable counter-
surgery, it is the most challenging skill required parts, are available. The only difference is
of a laparoscopic surgeon. that reusable clips are reloaded after each fir-
ing which may potentially delay clipping of a
• Extracorporeal Suturing targeted vessel.
The surgeon creates the knot outside the body
using a series of half-hitch knots that are • Titanium Clips
advanced into the abdomen through a port by Most mechanical clips using reusable clip
using a knot pusher. The suture lengths are applier are made from titanium. However,
usually longer than 70 cm. Care must be exer- they tend to slip off during dissection; there-
cised during extracorporeal suturing as exces- fore, multiple applications of at least 2–5 clips
sive traction during passing and redelivery of seem to be necessary for safe control of ves-
the suture may lead to “sawing” of the tissue. sels (Fig. 2).
• Intracorporeal Suturing • Polymer Ligation Clip System (Hem-o-lock™
This technique requires skill to manipulate the clips, Weck, USA).
needle, to pass it from one needle driver to the This clip system comprises of a self-sealing,
next, and to execute a series of knots. The hook-like mechanism that “lock” when
required suture length for this type of suturing applied correctly with fewer tendencies to slip
is usually between 12–17 cm. off as compared to titanium clips. It is a safer
alternative to control even significantly large
Ligation vessels such as renal vein or artery as it comes
Occluding the bleeding vessel by suture ligation in various sizes from the medium, large, and
is an effective way of hemostasis in surgery; extra-large.
The preferred method of clip system largely The two main categories of topical hemostatic
depends on the surgeon and also on the agents are physical agents, which promote hemo-
anticipated size of the vessels. Before the clip stasis using a passive substrate, and biologically
application, it is crucial to visualize both sides of active agents, which enhance the coagulation
the clip to ensure adequate tissue uptake and pre- process at the bleeding site [4]. Examples of the
vent inadvertent clipping of nontarget structure. commonly used hemostatic agents in laparos-
Ischaemic necrosis, perforation, and laceration copy are;
of surrounding tissues are common complica-
tions resulting from inadequate meticulous dis- hysical Agents or Dry Matrix
P
section before clipping a structure and incorrect Dry physical agents produce a matrix that acti-
clip application. vates the coagulation cascade and acts as a scaf-
fold for thrombus to form and build up. These
ndoscopic Stapling Devices
E agents are easy to use; however, they are less
This device sometimes referred to as vascular effective if bleeding is brisk.
endo stapler (Endo-GIA, Covidien, US; Endopath
Flex, Ethicon, US) is ideal in situations where • Oxidized Regenerated Cellulose
mechanical clips are not large enough to seal large Oxidized regenerated cellulose (ORC) is a
caliber vessels [3]. Stapler height of 2.0–2.5 mm dry, absorbable sterile mesh (Surgicel™) that
can safely occlude major vessels or vascular ped- is derived from cotton cellulose which can be
icles as a newer device utilizes three lines of sta- applied directly to an area of bleeding
ples for simultaneous vascular sealing and cutting. (Fig. 3). Results are optimal if bleeding is
However, modern endo staplers are bulky instru- minimal (i.e., oozing). ORC is commonly
ments that require 12–18 mm access port to work used to control bleeding at vascular anasto-
in a limited space and equipped with a rotating or motic sites, the cut surfaces of solid organs
angulating system hence costly [1]. The firing of (Fig. 3), and retroperitoneal or pelvic sur-
stapler requires some training beforehand to avoid faces after lymphadenectomy [4]. Apart from
stapler “malfunction” as the improper technique mechanical effects, cellulosic acid helps
may cause insufficient sealing of vessel resulting hemostasis by blood protein denaturation.
in life-threatening bleeding. Because ORC is pliable, it can be rolled and
passed easily through laparoscopic trocars. A
single-layer sheet is fully absorbed in approx-
Tissue Hemostasis Agents imately 14 days.
Topical hemostatic agents and tissue sealants or

adhesives are available as an adjunct to manage
bleeding during open surgery or laparoscopy when
conventional hemostatic techniques (mechanical,
thermal, and chemical) are inadequate or impracti-
cal [1, 4]. Topical hemostats and sealants have
become essential tools of laparoscopic surgery due
to their ability to reduce bleeding complications.
These are especially convenient for diffuse bleed-
ing from the nonanatomic region, bleeding near
sensitive structures, e.g., nerve, and bleeding in Fig. 3 Hemostasis by application of oxidized regenerated
patients with coagulopathy. cellulose (Surgicel™) to liver parenchymal surface
Hemostasis in Laparoscopic Surgery 43
• Recently, ORC has been manufactured into a Recently, human thrombin and recombi-
powder form (Surgicel® Powder) that can nant thrombin are available for use and have
penetrate the blood to stop bleeding at the primarily replaced bovine thrombin.
source. It comes with a unique endoscopic 2. Fibrin Sealant
applicator for use in laparoscopy. Fibrin sealants or glues are typically a mix-
• Gelatin Matrix ture of a two-component system; a solution of
Gelatin (e.g., Gelfoam, Surgifoam™) is a concentrated fibrinogen and factor XII, and a
hydrocolloid made from partial acid hydroly- solution of thrombin and calcium. When the
sis of porcine-derived collagen that is whipped components are mixed immediately before use,
into foam and then dried. It is available in a solid fibrin matrix or clot forms [3]. Owing to
sponge or powder form. Gelatin sponge their liquid nature, they are readily used in lap-
absorbs blood or fluid up to 40 times its aroscopy which is then applied using a long
weight, and when saturated with blood, it applicator needle and a dual-lumen adapter.
expands up to 200% in its dimensions [4]. Fibrin sealant can control bleeding at vas-
The dry sponge is rigid and firm when dry, cular anastomotic sites. Use of fibrin glue in
but became soft and pliable after moistening conjunction with a gelatin sponge (Tisseel™)
thus able to be molded into any shape for is useful to control bleeding from superficial
easy passage through laparoscopic ports. cut surfaces but not from severe vascular
Hemostasis occurs when the sponge is bleeding. Human-derived fibrin glue
pressed for several minutes at the intended (Crosseal™) meanwhile has a shorter opera-
area and left in place. It is completely tive time but higher complication rate [1].
absorbed after 4–6 weeks. 3. TachoComb™ or Tachosil™
Made from dry, equine collagen bovine
iologically Active Agents
B thrombin, bovine aprotinin, and human fibrino-
These agents are commonly referred to as tissue gen, this fleece (TachoComb™, NycomedLinz,
adhesives or glues promote tissue sealing and Austria) works by mimicking the final steps of
support by reproducing the different phases of the human coagulation process [1, 3]. As the
coagulation. They are suitable for managing dif- fleece comes in contact with blood or body flu-
fuse bleeding from oozing surfaces but not from ids, it immediately activated and forms a patch
major vascular bleeding. The lack of adequate and hemostasis ensued. It must be applied cor-
adhesion strength enables any forceful bleeder to rectly to prevent premature activation of the
displace the products away from the bleeding tis- patch. Hence, for laparoscopy, the pre-rolled
sue. Some of these agents are; TachoSil™ is delivered by a special clamp.
TachoSil™ (human fibrinogen and equine col-
1. Topical Thrombin lagen) forms a dense tissue-like sealant at the
Topical thrombin that is reconstituted from surface of the parenchymal lesion or defect
a lyophilized powder is a bovine-derived within 3–5 min, following constant compression
thrombin component. It can be applied using and moisturizing with normal saline, and will be
a sprayer onto an oozing surface or applied replaced by vital tissue. Therefore, it can be
with a needle and syringe directly to a specific applied even when bleeding is absent and in
area of bleeding [3]. Topical thrombin can patients with coagulopathy. After proper appli-
also be used in conjunction with a bovine gel- cation, it is possible to subject the sealed surface
atin matrix agent (sponge or granules) that to further bipolar coagulation, or suturing with-
provides the thrombin with an immediate out jeopardizing the sealant effect. TachoSil™
scaffold for clot formation (Floseal™, has an anti-adhesive property that separates the
Surgiflo™). sealant tissues from other structures nearby.
Choice of Topical Hemostatic Agents sible, insert a gauze through a 10 mm port

site to achieve temporary tamponade (Fig. 1).
With various types of topical hemostatic agents 5. Apply gentle pressure with an atraumatic
available, the choice of which to use will depend grasper to the bleeding point where
on the character, amount, and location of bleed- identified.
ing; surgeon preference and cost considerations. 6. If the bleeding does not stop with direct iden-
Dry matrix agents are less effective when bleed- tification and pressure, convert to an open
ing is brisk; however, fibrin sealant is a more procedure.
appropriate choice when moderate bleeding is 7. If the bleeding stops with the above mea-
uncontrolled by other measures. sures, ensure that there are enough port sites
for adequate instrumentation. Insert extra
ports for better visualization and retraction,
Methods of Prevention and possibly for optimal triangulation if
of Hemorrhage During Laparoscopy suturing is required.
8. Place a mechanical clip on both sides of the
1. Visualize and identify all structures before area being grasped (Fig. 2).
division. 9. Irrigate and evaluate.
2. Avoid blunt avulsion or stripping of adhesions 10. If necessary, apply electrical and ultrasonic
and fat tissues. energy judiciously.
3. Safely apply energy to the area to be divided.
4. Preemptive clipping of a structure or dissect
generous enough if unsure about its vascular-
ity to allow prompt control if bleeding References
occurred after division.
1. Klingler CH, Remzi M, Marberger M, Janetschek
G. Haemostasis in laparoscopy. Eur Urol.
2006;50(5):948–57.
anagement of Active Hemorrhage
M 2. Newman RM, Traverso LW. Principles of laparoscopic
During Laparoscopy hemostasis. The SAGES manual. New York: Springer;
2006. p. 49–59.
3. Vecchio R, Catalano R, Basile F, Spataro C, Caputo
1. Avoid panic situation. M, Intagliata E. Topical hemostasis in laparoscopic
2. Avoid random application of energy or clips surgery. G Chir. 2016;37(6):266.
towards the presumed bleeding point. 4. Peralta E. Overview of topical haemostatic agents
3. Visually identify the bleeding without taking and tissue adhesives. In Cochran A, UpToDate;
2019. https://www.uptodate.com/contents/overview-
away necessary retraction. of-topical-hemostatic-agents-and-tissue-adhesives.
4. Suction the area with a suitable suction Accessed 1 May 2019.
device and avoid too much irrigation. If pos-
Imaging-Enhancing System
Visualization is one of the fundamental pillars rescent dye (indocyanine green-fluorescent

(including CO2 insufflation and instrumentation) imaging) to see beyond what can be viewed with
critical to performing MIS. Initially evolved from the naked eye, coupled with the advantage of
direct view through the laparoscope to indirect real-time application. Narrow-band imaging is
view on the monitor projected from a camera sys- primarily used in gastrointestinal endoscopy to
tem. Early advances were geared towards improv- detect mucosal pathologies, while ICG aid in
ing the image quality and reproduction of revealing specific structures beneath tissues and
stereoscopic vision. Current advancements assess tissue perfusion; it is finding interest for
involve in part or in combination, the application application in various MIS procedures.
of optical filters to manipulate specific light spec-
trums (narrow-band imaging) and the use of fluo-
Indocyanine Green-Enhanced
Imaging
A. Lee-Ong (*)
Department of Surgery, Manila Doctors Hospital, History of Indocyanine Green (ICG). ICG-
Manila, Philippines enhanced imaging is based on the properties of the
Philippine Center for Advanced Surgery, cyanine dye. The Kodak research laboratories
San Juan, Philippines developed the ICG dye in 1955 for near-infrared
Department of Surgery, Cardinal Santos Medical photography [1, 2]. Its FDA-approved medical
Center, San Juan, Philippines application began in 1956, initially used for quanti-
Department of Surgery, Quirino Memorial Center, tative measurement of hepatic and cardiac func-
Quezon City, Philippines tion; subsequently extended to use in ophthalmology
A. A. Buenafe with the investigation into its fluorescent properties
Philippine Center for Advanced Surgery, in the 1970s [1]. Its use was hindered by techno-
San Juan, Philippines logical limitations until recently with the develop-
Department of Surgery, Cardinal Santos Medical ment of improved digital imaging, allowing the
Center, San Juan, Philippines broad application of ICG imaging.
Department of Surgery, Rizal Medical Center, Rationale for Using ICG. Use of ICG has
Pasig, Philippines several advantages: good signal-to-noise ratio
Department of Surgery, Batangas Medical Center, where the target can be seen clearly due to the
Batangas, Philippines absence of background tissue auto fluorescence,
Department of Surgery, Asian Hospital and Medical rapid clearance of the dye allows repeated appli-
Center, Alabang, Muntinlupa, Philippines cations, the near-infrared light used to excite and
https://doi.org/10.1007/978-981-19-3755-2_8
46 A. Lee-Ong and A. A. Buenafe
Light Source
Optical Filter
IR color mode: 1
Infrared Light
Red Light
Blue Light IR color mode: 2
Green Light
Tissue
Fluorescent Dye
Fig. 1 How ICG-enhanced imaging works. (Source: Olympus)
fluorescence being viewed functions within the excreted unchanged into the bile. Hepatic clear-
tissue optical window allowing visualization to ance is at the rate of 18–24% per minute, with
about 5–10 mm deep, and the system itself exponential clearance observed in the first
merely requires simple affordable imaging 10–20 min. After the initial period, the clearance
devices [3]. The wavelengths below 700 nm are rate slows down, allowing trace amounts to
absorbed by hemoglobin and myoglobin, while remain for more than an hour; the half-life is
that above 900 nm are limited by lipid and water around 3–4 min [5]. Multiple or repeated applica-
absorption [4] (Fig. 1). tion is possible due to the rapid clearance of the
Properties of ICG. ICG is an amphiphilic, tri- dye [4, 6].
carbocyanine iodide dye with a molecular mass of Injected interstitially, the dye similarly binds
751.4 Da [1]. It is distributed as a powder and to proteins and is usually detected in the closest
reconstituted with distilled water with good solu- draining lymph nodes within 15 min and to the
bility, attaining an aqueous solution of 6.5 pH for regional lymph nodes after 1–2 h [2].
intravenous injection. The solution has limited sta- The lethal dose (LD50) is 50–80 mg/Kg in
bility to light and must be used within 6–10 h on animal studies and is practically nontoxic at the
dilution; once injected, it attains spectral stabiliza- standard dosage of <2 mg/Kg (0.1–0.5 mg/ml/
tion within seconds. The dye is excited with either Kg) provided the patient has no iodide allergy [1,
filtered (near-infrared) light or laser between 750– 2, 6].
800 nm [2]. The fluorescence is detected or viewed
around the maximum peak of 832 nm with specifi-
cally designated scopes and cameras [1, 2]. It pro- ome Applications of ICG Imaging
S
duces a nonlinear fluorescence quantum yield in in MIS
relation to the concentration.
Injected intravascularly, around 98% binds to Cholecystectomy. Bile duct injury (BDI) is the
plasma proteins (serum albumin, α-, and most dreaded complication of cholecystectomy;
β-lipoproteins) without altering the protein struc- the incidence ranges from 0.3% to 1.5% for the
ture at the same time preventing dye extravasa- laparoscopic technique. Even with the introduc-
tion and decreasing its tendency to aggregate. tion of the Critical View of Safety (CVS) concept
The concentration of the dye within the body by Strasberg, the incidence of bile duct injury
should be kept below 15 mg/L, as it starts to remains around 0.42% [7]. Often cited reasons
aggregate at higher concentrations, which will were aberrant anatomy and the distortion or mis-
result in “quenching” or a decrease in the fluores- interpretation of the biliary tract anatomy due to
cence yield. The other 2% is free in the serum; inflammatory changes. While intraoperative
eventually, both are taken up by the liver and cholangiography (IOC) is accepted to provide a
Imaging-Enhancing System 47
White (visible) Light Near Infrared (invisible) Light with ICG

Photos courtesy of Prof Luigi Boni, MD, Fondazione IRCCS - Ca’ Granda - Policlinico Hospital University of Milan
Fig. 2 Gallbladder and extrahepatic biliary ducts under sues. (Source: Pfiedler Education, Fluorescence Guided
white light (left) and the same area under ICG-enhanced Surgery: A Nurse’s Guide to ICG. 2020)
imaging (right) show target outline beneath overlying tis-
roadmap during surgery, it has several shortcom- impacted stone, remedied by milking the stone
ings such as increased operative time, the need into the gallbladder and allowing the gallbladder
for dedicated radiologic instrumentation and content to flow into the biliary duct. Intraoperative
trained staff, requiring partial dissection of the intravenous ICG injection (2–3 mL, 0.4 mg/Kg)
Calot’s triangle and the cannulation of the cystic may be done to clarify the cystic artery anatomy;
duct before IOC can be employed, and additional it is usually visualized after 60 s and lasting about
patient exposure to contrast and radiation. ICG 32 s, repeat dosing may be done after 15 min to
allows real-time visualization of the biliary ducts avoid quenching. In a comparative study against
and vessels before and during the dissection of IOC by Osayi et al. [9], the biliary anatomy was
the Calot’s triangle [7] (Fig. 2). visualized with ICG in 80% of cases where IOC
There is a wide variation in the dosage and could not. Similarly, Daskalaki et al. [10] noted a
timing of the ICG solution infusion for cholecys- high visualization rate ranging 95.1–99% visual-
tectomy. The dosage ranges from a single fixed ization of the biliary anatomy with ICG.
bolus of 2.5 mg to weight-based dosing (0.05– Bowel Anastomoses. Reconstruction after
0.5 mg/Kg). The timing varies widely, from just bowel resection in a gastrointestinal surgery has a
after induction of anesthesia to as long as 48 h wide rate for dehiscence (1–30%), with experi-
before surgery. Tsutsui et al. [3] suggested the enced hands, it is around 3–6%. One of the rec-
optimal timing of infusion to be around 15 h ognized risk factors for an anastomotic leak is the
before surgery to attain optimum contrast presence of poor local tissue oxygenation sec-
between the biliary tract against the background ondary to inadequate anastomotic vascular perfu-
liver and surrounding soft tissue. Report by sion. Traditional blood flow assessment is
Graves et al. [8] of successful visualization of the subjective and based on surgical evaluation of
cystic duct and common bile duct with direct bowel color, bowel peristalsis, pulsation of ves-
injection of 0.025 mg/mL ICG-bile solution into sels, temperature, and bleeding from the marginal
the gallbladder of 11 patients for cholecystec- arteries [11]. Usually, more than 10 min are nec-
tomy; the drawback to this technique is obstruc- essary for ischemia demarcation to become visi-
tion of the cystic duct or gallbladder neck by ble after vessel division [2]. More objective
transplant, urology, etc.) are ongoing. In gynecol-

ogy, oncology and endometrioses are the focus;
detection of sentinel lymph nodes (SLN) with
ICG may reduce the operative time and improve
SLN detection, while endometrioses encounter a
lack of robust evidence to conclude. In hepatobili-
ary surgery, investigations are directed towards
liver mapping, cholangiography, tumor visualiza-
tion, and liver graft evaluation; preliminary con-
cerns exist regarding limited tissue penetration
Fig. 3 Assessment of bowel perfusion for anastomosis:
ICG lighting-up perfused bowel segment (blue arrow) dis- and instances of false positive or negative results.
tant from the planned bowel resection site (yellow arrow). In general, there is a broad interest in applying
(Source: Olympus) ICG imaging to currently available diagnostic and
therapeutic interventions, and there is a need for
means have been suggested, such as Doppler more robust studies to provide clear-cut conclu-
measurement; however, this is cumbersome and sions and recommendations.
requires additional training. The injection of ICG
would allow real-time evaluation of bowel perfu-
sion before resection and completion of the References
anastomosis. To evaluate the perfusion of the

bowel, intravenous ICG injection is given using 1. Reinhart MB, Huntington CR, Blair LJ, et al.
Indocyanine green: historical context, current appli-
two boluses of 5 ml each at a concentration of cations, and future considerations. Surg Innov.
0.4 mg/Kg; the first, after the division of the vas- 2016;23(2):166–75.
cular pedicle to help choose the best-perfused 2. Boni L, David G, Mangano A, et al. Clinical appli-
site for resection and the second, just before per- cations of indocyanine green (ICG) enhanced fluo-
rescence in laparoscopic surgery. Surg Endosc.
forming the anastomosis to ensure adequate vas- 2015;29(7):2046–55.
cularization (Fig. 3). A systematic review on the 3. Tsutsui N, Yoshida M, Nakagawa H, et al. Optimal
use of ICG to assess perfusion in colorectal anas- timing of preoperative indocyanine green adminis-
tomosis concluded that the surgical plan was tration for fluorescent cholangiography during lapa-
roscopic cholecystectomy using the PINPOINT(R)
changed in 10.8% of cases after application of endoscopic fluorescence imaging system. Asian J
ICG, and the leak rate was reduced from 7.4% to Endosc Surg. 2018;11(3):199–205.
3.4% [11]. A meta-analysis reported by Shen 4. Kaplan-Marans E, Fulla J, Tomer N, et al.
et al. [12] also suggested that ICG was associated Indocyanine green (ICG) in urologic surgery. Urology.
2019;132:10–7.
with a lower leak rate OR 0.27 (95% CI 0.13– 5. Desmettre T, Devoisselle JM, Mordon S. Fluorescence
0.53). The RCT looking into the use of ICG in properties and metabolic features of indocya-
colorectal anastomoses by Alekseev et al. [11] nine green (ICG) as related to angiography. Surv
noted a decrease in the leak rate among low rectal Ophthalmol. 2000;45(1):15–27.
6. Alander JT, Kaartinen I, Laakso A, et al. A review of
anastomoses (14.4% from 25.7%, p = 0.04). Indocyanine green fluorescent imaging in surgery. Int
J Biom Imaging. 2012;2012:940585.
7. Vlek SL, van Dam DA, Rubinstein SM, et al. Biliary
Summary tract visualization using near-infrared imaging with
indocyanine green during laparoscopic cholecystec-
tomy: results of a systematic review. Surg Endosc.
Currently, ICG imaging application in cholecys- 2017;31(7):2731–42.
tectomy for extrahepatic biliary tract visualization 8. Graves C, Ely S, Idowu O, et al. Direct gall-
and the assessment of bowel perfusion for anasto- bladder Indocyanine green injection fluores-
cence cholangiography during laparoscopic
moses have shown promising outcomes. Studies cholecystectomy. J Laparoendosc Adv Surg Tech A.
on its usage in other fields (gynecology, hepatobi- 2017;27(10):1069–73.
liary surgery, neurosurgery, pediatric surgery,
Imaging-Enhancing System 49
9. Osayi SN, Wendling MR, Drosdeck JM, Narula 11. Alekseev M, Rybakov EA-O, Shelygin Y, et al. A study
VK, et al. Near-infrared fluorescent cholangiog- investigating the perfusion of colorectal anastomoses
raphy facilitates identification of biliary anatomy using fluorescence angiography: results of the FLAG
during laparoscopic cholecystectomy. Surg Endosc. randomized trial. Colorectal Dis. 2020;22(9):1147–
2015;29(2):368–75. 53. https://doi.org/10.1111/codi.15037.
10. Daskalaki D, Fernandes E, Wang X, et al. Indocyanine 12. Shen R, Zhang Y, Wang T. Indocyanine green fluores-
green (ICG) fluorescent cholangiography during cence angiography and the incidence of anastomotic
robotic cholecystectomy: results of 184 consecu- leak after colorectal resection for colorectal cancer: a
tive cases in a single institution. Surg Innov. 2014 meta-analysis. Dis Colon Rectum. 2018;61:1228–34.
Dec;21(6):615–21.
Instrumentations and Access
Devices
Introduction specialty widely performing laparoscopic proce-

dures. The evolution in design, ergonomics, and
Minimally Invasive Surgery (MIS) instruments variety has been pivotal for advancing endo-
are patterned after conventional hand instruments laparoscopic surgery to perform more complex
to perform similar specific functions; they are surgical procedures with safety and better out-
designed to pass and perform through small come. Various evolving concepts of MIS like
diameter ports and at a distance to the target tis- Single-site or reduced Surgery, Natural Orifice
sues. The development of instruments has Transluminal Endoscopic Surgery (NOTES),
evolved since the early period of MIS, starting Needlescopic Surgery, and Robotic-assisted
from the use of rudimentary gynecologic instru- Surgery have also pushed the development of
ments; at that time. Gynecology was the only features such as articulation control, pre-bent
configuration, smaller diameter, and robotic
instruments to meet specific needs.
A. Lee-Ong (*)
Department of Surgery, Manila Doctors Hospital, A better understanding of the features, ergo-
Manila, Philippines nomics, characteristics, and different instrumen-
Philippine Center for Advanced Surgery, tations is crucial for any surgeon before embarking
San Juan, Philippines on basic or advanced laparoscopic surgery.
Department of Surgery, Cardinal Santos Medical We can divide the instrumentations into three
Center, San Juan, Philippines categories: access the cavity or workspace, main-
Department of Surgery, Quirino Memorial Medical tain the working space, and perform the surgical
Center, Quezon City, Philippines procedures. Let us analyze the role of these
A. A. Buenafe groups.
Philippine Center for Advanced Surgery, San Juan, The development of these devices has also
Philippines evolved to respond to the requirements of new
Department of Surgery, Cardinal Santos Medical MIS concepts.
Center, San Juan, Philippines In the first two groups: access devices are
Department of Surgery, Rizal Medical Center, Pasig, meant to gain entry into the workspace (i.e.,
Philippines abdominal cavity, chest, pre-peritoneal space,
Department of Surgery, Batangas Medical Center, etc.) while other devices are needed to maintain
Batangas, Philippines the space by the insufflated CO2 while allowing
Department of Surgery, Asian Hospital and Medical insertion of instruments necessary in the perfor-
Center, Alabang, Muntinlupa, Philippines mance of surgery.

https://doi.org/10.1007/978-981-19-3755-2_9
ccess Devices: Role

A the open technique; the cone serves as a stop-
and Characteristic per preventing air leaks while the blunt trocar
prevents visceral injury as it is inserted.
Access devices’ primary purpose is to gain entry 3. Optical trocar. It is a specially designed trocar
to the workspace, the insufflation of CO2, main- that is utilized to access the abdominal cavity
tain a pressurized workspace, and serve as a con- (Fig. 3). It is beneficial in certain situations
duit for instruments to pass through. like obesity or when the access with Veress or
open technique is at risk of injury. The trocar
1. Veress needle. A specially designed instru- has a transparent tip that allows a view
ment to enter the abdominal or thoracic cavity through. The trocar accommodates an endo-
using the closed technique (Fig. 1). It consists laparoscope (0° scope preferred), allowing
of an outer sharp cutting needle and an inner visualization of each layer of the abdominal
blunt spring-loaded stylet. During insertion, wall as it is inserted into the abdominal cavity.
the needle encounters resistance; the blunt The trocar may have either a cutting or a dilat-
stylet retracts, exposing the sharp outer sheath ing tip, with the latter preferred.
which facilitates penetration of the structure; 4. Hand-assist port. Ports are designed to accom-
when it enters a cavity, the blunt stylet springs modate the passage of a hand (for assisting)
forward beyond the outer sheath to protect the while maintaining intraperitoneal pressure
viscera within. Once proper intraperitoneal (Fig. 4).
placement has been ascertained using 5. Single or Reduced Ports. These ports are spe-
accepted maneuvers, insufflation of the peri- cifically designed for the single or reduced
toneal cavity may be initiated and followed by port technique. They are introduced through a
the insertion of working ports. single access point and allow multiple instru-
2. Hasson trocar. Composed of a cannula with an ments and camera endoscope to be inserted.
adjustable sliding cone and a blunt-tip trocar There are reusable and disposable devices,
(Fig. 2). Intended to be inserted into the with different diameters and sizes. Also, the
abdominal cavity after access is achieved with type and number of instrumentations that can
a b
Fig. 1 (a) Veress needle. (b) Needle tip magnified showing inner blunt spring-loaded tip
Fig. 2 Hasson trocar
Fig. 3 Optical trocars

Instrumentations and Access Devices 53
Fig. 4 Hand-assist port
Fig. 6 Showing the extended cutting blade of a trocar
(cutting or non-cutting). Maneuver during inser-

tion through the abdominal wall: with long axis
90° to the wall, back and forth clockwise-
counterclockwise rotation while slowly pushing
in. Port can be held either two-handed (one hand
on the head applying pushing and rotational
force, while the second hand holds the cannula to
prevent sudden slippage when the tip enters a
Fig. 5 Olympus Tri-port cavity), or one-handed (the head in the palm with
a finger or two along the cannula to act as a stop-
be inserted may vary. Fig. 5 shows Olympus per when the tip enters a cavity)
Tri-port, a form of Single/Reduced port.
(a) Bladed/Cutting—facilitated by a blade under
a spring-loaded cover (Fig. 6) that springs
evice to Maintain the Working
D forward, covering the cutting blade and lock-
Space ing in place once the device enters the
abdominal cavity protecting the viscera
Trocars or Conventional ports. The trocar or port within.
is generally composed of two parts: the outer (b) Pyramidal—pyramidal tip is meant to expe-
cannula and the inner trocar. The outer cannula dite passage through tough tissue easier than
usually has a valve that allows entry of hand the cone-tip, but with less trauma than a
instruments while maintaining the workspace, cutting-tip (Fig. 7).
and a stopcock allows the insufflation and evacu- (c) Dilating /non-cutting Tip—are usually
ation of the workspace. Like hand instruments, pointed conical tip trocars intended to push
these can be reusable or single-use, have specific aside the tissue fibers without cutting (Fig. 8).
features to the outer sheath (flexible, ridges, or
fixation balloon), and have varying trocar tip We will now analyze the variety and charac-
designs with different penetrating capabilities teristics of the instrumentations most frequently
utilized to perform procedures. Instrumentations 1. Handle—this part controls the instrument tip
have different ergonomics, and they are mainly and its function; it has features that contribute
designed to accomplish a task or a determined to the additional functions of the instrument
action. Any surgeon must make proper and cor- and configuration that allows for the user’s
rect use of each one. ergonomic preference.
(a) Configuration/Design—the primary inter-
face with the user provides control of the
Endo-Laparoscopic Instruments: instrument’s jaw action and has varying
The Basic designs that allow for user preference that
enhance comfort and ease of use (Fig. 10).
The laparoscopic hand instruments (Fig. 9) are (b) Locking mechanism—provides securing
generally composed of three parts/sections: mechanism for the jaws to minimize hand
strain when grasping tissues for extended
periods.
(c) Rotation knob—provides the means to
rotate the instrument tip 360° around its
long axis.
(d) Electro-surgical post connects either
monopolar or bipolar cable from the
electro-surgical device to provide tissue
coagulation or cutting capability.
2. Shaft—is a metal sheath through which the
insert runs and connects to the instrument
handle. Together with the insert, determine
the instrument’s length, based on the distance
to the target tissue (dependent on varying fac-
tors: adult (33 cm) vs pediatric (23 cm), non-
Fig. 7 Trocar with a pyramidal tip obese vs obese (43 cm), or preferred point of
access). This part is usually covered by a non-
conductive material (silicone or plastic) to
isolate the current passing from the electro-
surgical post to the instrument tip and prevent
collateral injuries.
3. Instrument Insert/Tip—the main part that
determines the function with specifically
Fig. 8 Trocar with a conical tip designed jaws.
Jaw insert
Handle
Sheath
Fig. 9 Expanded view of the parts of a laparoscopic instrument

Axial handle Vario handle Multifunctional handle
Ring handle Shank handle
Fig. 10 Various handle designs in laparoscopic instruments
Fig. 11 Jaw action of

laparoscopic instruments a b
oncepts of Hand Instrument

C allows the user to focus on the mobile
Variations jaw (Fig. 11a).
2. Tip Function
1. Jaw Action (a) Dissectors—are meant to expose, isolate,
(a) Double-action—both jaws of the tip or separate tissue structures. The jaws
move; it is the preferred action for dissec- are usually of the double-action type,
tors as it allows for greater tissue separa- fine-tipped, and with the curved jaws
tion and access to varying tissue planes preferred by most users to allow better
(Fig. 11b). tip visualization. The most popular of
(b) Single-action—one jaw moves while the which is the Maryland dissector
other remains fixed; the mechanism (Fig. 12).
allows for the force applied via the han- (b) Graspers—are meant to hold on to struc-
dle to be concentrated on the mobile jaw tures to allow exposure, manipulation, or
providing a firm grip. In instruments retraction. The jaws may be of atraumatic
intended for delicate functions, this design for delicate tissues (Fig. 13), dou-
Fig. 15 Curved scissors
Fig. 12 Maryland dissector tip
Fig. 16 Curved scissors with serrated blades
Fig. 13 Fenestrated atraumatic grasper tip
Fig. 17 Hook scissors
Fig. 18 Micro scissors
Fig. 14 Straight scissors ii. Curved scissors—preferred by most

users, the curvature of the blade
ble- or single-action, with or without fen- allows a better view of the tip
estration (for a more secure grip, by (Fig. 15).
allowing the tissue to mold into the gaps), iii. Serrated scissors—ridges on the
with or without teeth (affords secure grip blade minimizes tissue or suture slip-
on tougher tissues). page (Fig. 16).
(c) Scissors/Shears—primarily meant for iv. Hook scissors—encircles the struc-
cutting or sharp dissection, has varying ture before cutting, assuring firm and
designs for specific functions. solid grip (Fig. 17).
i. Straight scissors—mainly for cutting v. Micro scissors—facilitates partial
and dissection (Fig. 14). cutting of structures (Fig. 18).
3. Insulation—In MIS, electro-surgical energy

use plays a crucial part in dissection and
hemostasis. The nonconducting material (usu-
ally plastic or silicone) covering the instru-
ment shaft prevents the conduction of
electrical current to surrounding tissues and
isolates the flow toward the instrument’s tip,
allowing use even when the instrument shaft
is in contact with other structures.
4. Reusability Fig. 19 Irrigation-suction instrument
(a) “Reusable” instruments are meant to be
used multiple times. They are constructed
of durable materials, usually more rigid, tion tip usually has multiple fenestrations that
and are expected to withstand repeated not only facilitate suctioning but decrease the
use and cleaning and sterilization pro- chance of obstruction by surrounding tissue
cessing cycles. They are also designed to (Fig. 19). Some are designed with an electro-
be readily dismantled to allow thorough surgical attachment that allows for simultane-
cleaning and have replaceable parts for ous suctioning of fluids and coagulation of
easy maintenance. tissue, advantageous when the target area is
(b) “Disposable” instruments are also termed constantly flooded.
“single-use,” they came about in response 2. Knot pushers—are usually long rods with
to the perceived high acquisition and specially designed tips used to perform extra-
maintenance cost of reusable instru- corporeal knot tying (Fig. 20a, b). The knots
ments. They are usually manufactured are thrown outside, utilizing this instrument to
from less costly materials, generally less push the knot through the cannula and secure
robust, relatively flexible, cannot be dis- it inside.
mantled for cleaning, and quickly wears 3. Needle drivers/holders—are intended solely
down. for executing intra-corporeal suturing and
(c) “Reposable” instruments arose from the knot tying. These instruments have single-
combination of terms “reusable” and action, tough and robust jaws and, on occa-
“disposable”; meant to describe the cate- sion, may have tungsten inserts or diamond
gory of instruments having the beneficial coating to ensure surface hardness and secure
characteristic of both. Reusable part (usu- grip on the needle and suture, a rigid and
ally the handle) and disposable part (the sturdy shaft that can withstand applied rota-
insert and shaft, commonly scissors) tional forces, and a ratchet mechanism.
components; supposed to integrate fea- Various jaw configurations are available:
tures: a sturdy instrument with low acqui- straight, curved, and self-aligning (designed
sition cost and eliminate the need for to orient the needle perpendicular to the jaws);
maintenance. the most versatile being the straight jaws
which allow needle positioning in variable
orientation (Fig. 21).
Specialized Endo-Laparoscopic 4. Retractors—similar to those used in open sur-
Instruments gery, provide exposure by moving aside
mobile structures such as small intestines,
1. Irrigation and Suction instruments—meant to solid organs, or stomach. They may be hand-
evacuate fluid by suction and dislodge adher- held or fixed to a bracket attached to the oper-
ent debris using pressurized water. The suc- ating table.
Fig. 20 (a) Knot-

pusher instrument, (b) a KNOT PUSHERS
Various tip-design of
knot-pushers
b
KN-1 KN-2 KN-3 KN-4 KN-5 KN-6
Fig. 21 Needle handler Fig. 23 Fan-retractor
Fig. 24 Snake-retractor
through an epigastric puncture site,
maneuvered into position under the liver,
and fixed to a bracket.
(b) The Hand-held retractors—meant to be
operated by an assistant, allows for repo-
Fig. 22 Nathanson retractor sitioning as the procedure progresses, a
dynamic retractor. Once the desired
retraction is achieved, it may also be fixed
(a) The Nathanson retractor is designed to to a table-attached bracket and becomes a
retract the liver (Fig. 22); it is inserted static retractor.
i. Fan-retractor—has a folding head that Adrales G, Park A. Technological and instrumentation

aspects of laparoscopic hernia surgery. In: LeBlanc
spreads open like a hand-held fan K, editor. Laparoscopic hernia surgery: an opera-
when deployed (Fig. 23). tive guide. Oxford University Press, Inc; 2003.
ii. Snake-retractor—is a floppy metallic p. 7–15.
tube that assumes a specified configu- Carol EH, Scott-Conner. The SAGES manual. New York:
Springer-Verlag; 1998.
ration and stiffens up when the tension Goel A. Laparoscopic hand instruments, accessories and
knob is activated (Fig. 24). ergonomics. In: Kriplani A, Bhatia P, Prasad A, Govil
D, Garg HP, editors. Comprehensive laparoscopic sur-
gery. New Delhi: Sagar Printers; 2007. p. 9–19.
Palanivelu C. CIGES atlas of laparoscopic surgery. New
Further Reading Delhi: Jaypee Brothers Medical Publishers, Ltd.;
2000.
Ahmed HO. Color atlas of laparoscopy. Suleimani:
University of Suleimani; 2008. p. 31–140.
Operating Room Setup and Patient
Positioning in MIS
Crucial in any surgery, the performance and the action between tubing and cables will make your
outcome depend not only on the surgeon’s skills surgery safer, elegant, and less stressful.
and patient preparation but also on the setup of Moreover, the correct position of the patient to
the operating room (OR) and positioning of the the endo-laparoscopic devices, monitor, and pro-
patients. In endo-laparoscopic surgery, we work cedures is fundamental. The position depends on
with technology like cameras, monitors, insuffla- the procedure we intend to perform and where
tors, energy devices, and more. They are con- the surgical team will position in relation to the
nected and interconnected by several cables and patient and the video monitor. Also, to surmount
tubings. It is vital for patient’s and OR Staff’s challenges like visceral retraction, we may need
safety that they be easily accessible in a fast and to tilt the patient, requiring preparation to avoid
timely manner in case of any emergency or unex- patient falling or sliding from the OR table.
pected event. Avoid entangling of cables, or inter-
A. Lee-Ong (*) Operating Room Setup

Department of Surgery, Manila Doctors Hospital,
Manila, Philippines It depends on the size of your operating theater
Philippine Center for Advanced Surgery, and the provision for the support of additional
San Juan, Philippines equipment. In general, the endo-laparoscopic
Department of Surgery, Cardinal Santos Medical camera system is on a cart and can be easily
Center, San Juan, Philippines
rolled and placed around the operating table
Department of Surgery, Quirino Memorial Center, accordingly. In other cases, the endo-laparoscopic
Quezon City, Philippines
camera system can be mounted on a boom arm
A. A. Buenafe and can be readily shifted around; in this so-
Philippine Center for Advanced Surgery,
San Juan, Philippines called Integrated Operating Theater, additional
monitors are placed on a swing arm that can be
Center, San Juan, Philippines moved and adjusted to best fit the surgeon’s
needs. In general, the monitor stands along the
Pasig, Philippines axis: surgeon—target organ, the rest of the
Department of Surgery, Batangas Medical Center, devices like insufflator, energy device, camera
Batangas, Philippines controller, recording, etc., can be placed nearby
Department of Surgery, Asian Hospital and Medical the operating table and are easy to access for
Center, Alabang, Muntinlupa, Philippines monitoring and setup.

https://doi.org/10.1007/978-981-19-3755-2_10
a b
Fig. 1 Endo-laparoscopic system: (a) Endo-laparoscopic-cart mounted, (b) Boom-arm mounted
a b
X-ray
th
es ne X-ray machine
ac th
An chi
e
m nes
machine
hin
a
m
A
Suct
/ Irrig
Anes Mo
Suct Anes nito
ESU
r
M
r
/ Irrig
ito
on
on
ito
M
itor
Mon
Su
Endo-lap
Endo-lap
ESU
ESU
Adv
r
Tower
Tower
Sur
Asst
Ca
m
As
Cam
st
ESU
Adv
Nur
Nu1
2
Nur
1
r
Nur
2
Instrument
Instrument table
table
Fig. 2 Suggested OR setup in (a) large room, (b) small room
It is essential to plan everything ahead and and working perfectly. For the OR Staff and the
before the patient is positioned on the table. surgical team, allow good interaction and spac-
Once the patient is draped, it will be cumber- ing. Usually, the operating surgeon and the
some to reposition any devices. Allow enough camera assistant stand together on the same
space for the anesthesia team to move around side of the patient and the opposite side of the
and monitor the patient; if you need additional targeted organ, allowing space for triangulation
equipment like ultrasound, C-arm, various and the assistant on the contralateral side to
energy devices, laser, etc., plan and simulate help.
the position. It is also essential to check that all Figures 1a, b, 2a, b, and 3 are typical operating
the devices are correctly plugged in, powered, room setups for different surgical procedures.
Operating Room Setup and Patient Positioning in MIS 63
Anes
Cam
Monitor
Monitor
Sur
M
on
Instrument ito
r
table
Nur
1
Anes
Nur
1
Instrument
table Ca
m Sur
Lap Appendectomy TOETVA
Anes
M
or
on
nit
ito
Mo
r
Anes
Ca
m
Sur
As
st
Su
r
m
Ca
Nur
Nur
1
M
on
ito
r
Instrument Instrument
table table
Lap Inguinal Hernia R Lap Cholecystectomy
Fig. 3 Varying positions of the surgical team depending on the procedure

Anes Anes
M
or
M
on
nit
on
ito
ito
Mo
r
Ca
m
Asst
Asst
Sur
Sur
Mon
Cam
itor
itor
Mon
Nur
Nur
1
1
Nur
2
Instrument Instrument
table table
Lap Upper GI Lap Lower GI Left
Fig. 3 (continued)
these are rare events and comprehensive data on

Introduction to Patient Positioning the general incidence is lacking; however, they
gauged that postoperative neuropathies range
Similar to exposure in open surgery, patient posi- 0.10–3.2% for MIS, 0.8–6.6% for robotic-
tioning is a necessary preparation in MIS; knowl- assisted surgeries and suggests the overall inci-
edge of the conduct of the operation provides dence to be 2–5% [2, 3].
comprehension of appropriate port placements Factors such as operative time, body mass
and potential movement of the surgical team index (BMI), and the American Society of
around the patient. Optimal patient positioning Anesthesiologists (ASA) physical status classifi-
prevents inadvertent patient movement, protects cation contributed to the development of posi-
the patient from injuries, ensures unhindered tioning injuries. According to the study by
access to the port insertion area, and unencum- Gelpi-Hammerschmidt et al. on renal surgeries,
bered instruments over and surgical team traffic lengthy procedures (>5 h) have an increased
around the patient. chance of developing rhabdomyolysis.
The positioning augmented by intervals of Correspondingly, other studies confirmed a
unnatural positions (head down or up, or lateral decrease in positioning injuries and postoperative
tilt) allows gravity to retract the viscera away creatinine kinase as operative time decreases.
from the workspace. The prolonged operative BMI in both extremes is associated with an
time and maneuvering may generate compres- increased risk for injuries. High BMI presumably
sion, ischemia, shear, or stretch events that can aggravates the underlying forces that produce
cause positioning injuries like skin and tissue damage, while the rationale for low BMI is the
breakdown, transient neuropathies, compartment lack of subcutaneous soft tissue padding to pro-
syndrome, and rhabdomyolysis [1]. The 2017 tect the neurovascular structures. The poor ASA
review by Zilloux and Krupski revealed the belief classification is linked to factors (malnutrition,
diabetes, and peripheral vascular disease) that 90–120°, greater flexion can put a strain on the
make a patient prone to neuromuscular insults sciatic nerve, lesser flexion can promote venous
[2]. stasis that may lead to DVT, (3) angle of hip
abduction—90° or less, a greater angle can put a
strain on the obturator nerve, and (4) degree of
eneral Guidelines for Patient
G external hip rotation—should be kept to the mini-
Positioning mal, any degree of external rotation can increase
strain on the femoral, obturator, and sciatic nerve
Pressure Redistribution. The use of pressure dis- leading to nerve injury; the use of boot stirrup
persing devices and surfaces is critical to reduc- can provide improved positioning of the lower
ing pressure-induced skin and tissue breakdown. extremity.
The bony prominences of the body are areas
where weight-bearing points come in contact
with surfaces for prolonged periods and are prone Standard Surgical Positions in MIS
to developing these injuries. Dispersal of focal
pressure may be achieved using various types of Supine (Fig. 4). The supine position is the most
padding material (blanket, foam, pillow, silicone, common surgical position, also called the “dorsal
towel, or visco-elastic). recumbent” position. MIS procedures in this posi-
Deep Venous Thrombosis (DVT) Prevention. tion include those requiring access to the neck
MIS procedures have inherent factors (long oper- area, the abdominal cavity through anterior access,
ative time, extremes of positioning, and pneumo- or for inguinal hernias. The patient is positioned
peritoneum) that contribute to the risk of with the head and spine in a horizontal line with
developing DVT. The application of anti- the hips parallel to each other with the legs posi-
thromboembolic stockings and/or sequential tioned straight and uncrossed. The arms are posi-
compression devices has been shown to mini- tioned at the patient’s sides or abducted. The table
mize DVT incidence in MIS [4]. straps are applied loosely above the knees.
Upper Extremities Positioning [1, 3]. The Modified Lithotomy (Fig. 5). In this position, the
most effective means of avoiding brachial plexus hips are flexed, with legs abducted, the knees bent,
injuries is to secure the arms carefully at the and the buttocks at the edge of the table; the arms
patient’s sides, the palms resting against the may be secured at the sides or abducted. Procedures
patient with the elbows padded, and the draw using this positioning may require concurrent or
sheet extends about the elbow and secured under sequential access to several quadrants of the abdom-
the patient making sure it is not too tight to inter- inopelvic cavity and the perineal area.
fere with blood pressure cuff and intravenous Prone (Fig. 6). Generally used for cases
lines. Avoid pronation of the arm, as this can requiring access to the esophagus, the back, and
expose the ulnar nerve to possible pressure. the retroperitoneal area using dorsal access. After
When arms are to be abducted, they should be
placed level with the bed and not more than 90°
from the patient’s side. Avoiding shoulder braces
and wrist straps is advised; however, the shoulder
braces should be positioned at the acromiocla-
vicular joints when needed.
Lower Extremities Positioning [1, 3]. For the
lower extremities, especially for the lithotomy
position, four elements of positioning should be
kept in mind: (1) angle of hip flexion—60–170°,
should never be >180° as it places strain on the
lumbar spine, (2) angle of knee flexion—between Fig. 4 Supine
Fig. 5 Modified lithotomy

Fig. 7 Lateral decubitus
Common Modifications
Trendelenburg and Reverse Trendelenburg

(Fig. 8a, b). This modification may be added to
any of the basic positions by placing the body on
an incline. The Trendelenburg position elevates
the feet above the head at an inclination of about
15–30°; the reverse Trendelenburg does the
Fig. 6 Prone opposite—head elevated above the feet. The for-
mer allows gravity to pull the intra-abdominal
induction of anesthesia, the patient is positioned organs away from the pelvis; the latter, the vis-
face down with pads placed under the chest, hip, cera to fall away from the upper abdomen.
and thighs while verifying lung expansion is not Split Leg (Fig. 9). This variation applied to the
restricted. The arms are brought down and for- standard supine position allows the surgeon to
ward next to the head, the elbows flexed, hands stand between the legs when the patient is in
pronated, and padding at the elbows. The head reverse Trendelenburg and be nearer to the upper
may be turned to one side or placed on headrests abdomen access, which is frequently employed
designed to protect the airway. in bariatric and other upper gastrointestinal
Lateral/Lateral Decubitus (Fig. 7). The procedures.
patient lies down on the side contralateral to Head extension (Fig. 10). The neck extension
the intended workspace side. The lateral posi- modification in the supine position is specific for
tioning is used for access to the thorax, kid- access to the thyroid and parathyroid. The patient
neys, and retroperitoneal space. Paddings are is initially positioned supine and anesthesia
situated at the head, thorax, and legs; the arms induced via nasotracheal intubation. The shoul-
are placed on supports, and bracing supports ders are raised with padding or sandbag, and the
may be positioned at the back or anterior at the neck is slightly extended with the head secured
hip area. over a donut ring.
Fig. 10 Head extension

b
References
1. Agostini J, Goasguen N, Mosnier H. Patient position-
ing in laparoscopic surgery: tricks and tips. J Visc
Surg. 2010;147(4):e227–32.
2. Zillioux JM, Krupski TL. Patient positioning during
minimally invasive surgery: what is current best prac-
tice? Robot Surg. 2017;4:69–76.
3. Barnett JC, Hurd WW, Rogers RM Jr, et al.
Laparoscopic positioning and nerve injuries. J Minim
Fig. 8 (a) Trendelenburg and (b) Reverse Trendelenburg Invasive Gynecol. 2007;14(5):664–72.
4. Millard JA, Hill BB, Cook PS, et al. Intermittent
sequential pneumatic compression in prevention of
venous stasis associated with pneumoperitoneum
during laparoscopic cholecystectomy. Arch Surg.
1993;128(8):914–8. discussion 8–9
Fig. 9 Split Leg
Surgical Smoke: Risks and
Mitigation Strategies
Introduction they harbor these chemicals and biological com-

ponents, and have shown to carry mutagenic and
As the usage of electrocautery, ultrasonic scal- carcinogenic potential.
pels, and lasers have become commonplace, oper- Factors affecting the amount and content of
ative staff and patients alike are at increased risk smoke produced does include type of procedure,
of exposure to dangerous surgical smoke emanat- surgeon’s technique, pathology of target tissue
ing from these devices. Terms like “smoke,” (e.g., presence of bacteria or virus), type of energy
“plume,” and less commonly “aerosol” are used device, power levels used, and the amount of cut-
to refer to by-products of laser tissue ablation and ting, coagulation, or ablation performed [3]. The
electrocautery, whereas “plume,” “aerosol,” and smoke produced by each energy device has its own
“vapor” are associated with ultrasonic dissection. unique properties, comprising of aerodynamic
“Smoke,” although not formally accurate in all particle size, chemical makeup, and biological
cases, is a widely accepted term used to describe constituents. For instance, electrocautery produces
surgically generated gaseous by-product [1]. the smallest aerodynamic particle size, followed
Surgical smoke contains particulates like car- by laser tissue ablation creating larger ones while
bon monoxide, polyaromatic carbons, benzene, harmonic scalpels produce the largest particle size.
hydrogen cyanide, formaldehyde, viable and The smaller the size, the further the distance these
nonviable cellular material, viruses, and bacteria particles travel, and they pose a higher chemical
[2]. These particulates pose a risk to surgeons, concern. Larger particles, on the other hand, raise
operating theater personnel, and patients because more concerns from a biological aspect [1].
Studies have compared the deposition of par-
ticulate matter in ten different tissues, and have
shown that the liver produced the highest number
S. Malik (*)
Department of General Surgery, Allama Iqbal of particles, skeletal muscle and renal tissues pro-
Medical College, Lahore, Pakistan duced medium mass of particulate matter, while
F. Khairi other tissues produced significantly less particu-
General Surgery Services, Alexandra Hospital, late mass [4].
Queenstown, Singapore Particles that are greater than 5μm can deposit
S. Wijerathne on walls of the nose, pharynx, trachea, and bron-
General Surgery Services, Alexandra Hospital, chus whereas particles smaller than 2 μm are
Queenstown, Singapore deposited in the bronchioles and alveoli.
Minimally Invasive Surgery Centre, National Considering that 77% of plume is in the inspir-
University Hospital Singapore, Singapore, Singapore able range, it is concerning that smoke can cause
https://doi.org/10.1007/978-981-19-3755-2_11
70 S. Malik et al.
acute and chronic inflammatory changes, includ- its contents [1]. The chimney effect, first described
ing alveolar congestion, interstitial pneumonia, in 1995, stipulates that cancer cells are aerosolized
bronchiolitis, and emphysematous changes in the during laparoscopic surgery and can leak from
respiratory tract [5]. around the cannula during the procedure. The
Multiple carcinogens have been identified in localized inflammation from the trauma caused by
surgical smoke, with butadiene and benzene cannula and trocar insertion increases the potential
showing 17- and 10-fold higher concentrations for cancer cells to implant. It was also suggested
than second-hand smoking. Several laboratory that pneumoperitoneum creates a pressure gradi-
and animal studies have demonstrated smoke ent with resulting outflow of gas and floating
from laser and electrocautery surgery causing tumor cells through port wounds, creating a chim-
acute and delayed carcinogenic effects on humans. ney effect that does not occur in a standard wound
Although there is no direct evidence at present to [10]. Smoke also limits surgical field visibility,
show that surgical smoke is carcinogenic to which poses direct harm to patients.
humans, there are persistent concerns [5].
Besides chemical components, mutagenicity
and cytotoxicity also pose great concerns to users Mitigating the Risks
of lasers, electrocautery, and powered surgical
instruments. Tomita et al. quantified the muta- Once we recognize that surgical smoke is essen-
genic effect created by thermal destruction of just tially an occupational hazard, it is important to min-
1g of tissue to be equivalent to three to six ciga- imize its production and have proper evacuation
rettes [6]. Additionally, studies have shown systems or protocols in place. It is also vital to raise
smoke produced from breast tissue has the muta- awareness among surgeons and operating theater
genicity of a TA98 strain of Salmonella, and personnel regarding the dangers of surgical smoke.
another study demonstrated that it induced cyto- Surgeons can minimize the production of sur-
toxicity in human small airway epithelial cells gical smoke by avoiding unnecessary tissue abla-
and mouse macrophages [7]. tion and using shorter, precise bursts. Assistants
Surgical smoke, produced with or without a may also aid in capturing smoke with a suction
heating process, contains bio-aerosols with via- wand. A recently unpublished study had shown
ble and nonviable cellular material that conse- that a suction wand can effectively capture
quentially poses a risk of infection such as HIV, 95–99% of smoke if the tube’s orifice is within 2
hepatitis B virus, and human papillomavirus inches of the smoke source [11].
(HPV) [8]. Although the possibility of disease Small particles less than 1.1 μm constitute 77%
transmission via surgical smoke exists, actual of particulate matter found in surgical smoke [12].
documented cases of pathogen transmission are Because of this, most conventional surgical masks
rare. Only one such case has essentially been do not have sufficient filtering or snug-fitting attri-
proven, whereby a surgeon contracted laryngeal butes to provide respiratory protection. A study by
papillomatosis after treating anogenital condy- Gao et al. had shown that wearing at least N95 res-
loma with a laser. HPV types 6 and 11, the same pirator and N100 filtering face piece respirator
types in anogenital papillomatosis, were found in could offer more protection to wearers [13].
this individual’s larynx, a very uncommon area of
infection, which would suggest direct contact as
a route of transmission [9]. Evacuation Systems
Patients are also at risk from surgical smoke,
particularly during laparoscopic procedures The National Institute for Occupational Safety
whereby smoke gets trapped in the peritoneal cav- and Health (NIOSH) of the United States recom-
ity. Potential complications include carbon mon- mends a combination of general room and local
oxide toxicity, port-site metastases via chimney exhaust ventilation (LEV) to remove airborne
effect, and toxicity to peritoneal compartment and contaminants generated by surgical devices. They
Surgical Smoke: Risks and Mitigation Strategies 71
The same applies to surgeons as there were raised

concerns of the risk of coronavirus transmission
in the operating room. Specifically, the elevated
risk during intubation and extubation from the
anesthetic standpoint, as well as the risk of
release of potential infectious particulates in lap-
aroscopic smoke.
Past research had shown that laparoscopy can
lead to aerosolization of blood-borne viruses but
there has been no evidence to support that this
effect is seen with COVID-19, nor that it is iso-
Fig 1 Smoke evacuation pencils and tubing lated to laparoscopic procedures. However, to err
on the side of caution, it is prudent to treat the
advocate suction devices with a capture velocity coronavirus as exhibiting similar aerosolization
of 100–150 feet per minute [13]. Three such suc- properties. The UK and Ireland Intercollegiate
tion devices utilizing LEV include smoke evacua- Board have advised to consider laparoscopy only
tion wands, electrosurgical unit (ESU) pencils in selected cases whereby the clinical benefit of
(Fig. 1), and cell foam technology. the patient outweighs the risk of viral transmis-
ESU pencils are attached to tubing, which in sion [16].
turn connects to smoke evacuation filters. The lat- Assigning designated operating theaters for
est device based on cell foam technology operates confirmed and suspect cases of COVID-19 can
by having an open cell foam core sandwiched aid to streamline patient movements, limit the
between layers of nonporous plastic to keep number of staff and equipment needed, as well as
smoke within the device and prevent loss of suc- limiting contamination to specific areas. Negative
tion power. The LEV machines used are in turn pressure ventilation can curb contamination of
connected to ultra-low particulate (penetration) surgical smoke via doors and vents. There had
air (ULPA) filters that include activated charcoal been recommendations to stop positive pressure
which absorbs and deodorizes chemicals and ventilation during the procedure and for at least
odors present in smoke [13]. Filters should also be 20 min after the patient has left the theater; how-
used in the exhaust port of the collection device to ever, the risks associated with positive pressure
prevent contents of smoke from leaking [14]. ventilation have not been quantified [17].
Alternatively, high-efficiency particulate air Smoke extraction is crucial and can be
(HEPA) filters that are placed on top entry ports achieved with a general ventilation system, local
of suction canisters can trap particulates effec- extraction at the site of surgery, and use of per-
tively. Combination of HEPA filters with activated sonal filtration masks, as discussed before. The
carbon called “high efficiency gas absorption” smoke evacuator can be of two types one without
(HEGA) filters successfully prevent surgeons from the triple filter and the other one with a triple fil-
volatile organic compounds and chemical vapors. tering tube (Figs. 2 and 3a, b). At present, the
Additionally, using activated carbon fiber filter most effective smoke evacuation system is the
during laparoscopic operations can dramatically triple filter, which includes a prefilter that traps
reduce carcinogens by more than 85% [15]. large particles, an ULPA filter, and a special char-
coal that captures toxic chemicals.
There are however nonfiltration devices avail-
Special Considerations able in the market that can evacuate smoke as
well. The Ultravision™ system removes smoke
The COVID-19 pandemic had drastic ramifica- particulates during electrosurgical procedures, as
tions towards society and many had to adapt to an aid to maintain clear visual field. This system
the “new normal” and change work practices. is not restricted by particle size, and it has been
72 S. Malik et al.
Fig 2 AirSeal intelligence unit
a slowly at the end if an incision is required for

specimen extraction [16].
Conclusion
Surgical smoke contains harmful particulates and

although more research is required to determine
b its direct effect on health, we must be wary of its
long-term effects. There are many mitigation
strategies that can be applied, ranging from filtra-
tion masks to sophisticated smoke evacuation
systems. The most important step however is to
first and foremost educate healthcare workers
that surgical smoke is an occupational hazard,
and should be treated seriously as such.
Fig 3 (a) Airseal iFS without Triple lumen filtered tube,

(b) Airseal iFS with Triple lumen filtered tube
References
demonstrated to remove more than 99% of all 1. Barrett W, Garber S. Surgical smoke: a review of the
literature. Surg Endosc. 2003;17(6):979–87. https://
smoke particulates [16]. doi.org/10.1007/s00464-002-8584-5.
Methods recommended for laparoscopic sur- 2. Steege AL, Boiano JM, Sweeney MH. Secondhand
gery include the use of balloon ports to reduce smoke in the operating room? Precautionary prac-
the risk of inadvertent displacement of trocars tices lacking for surgical smoke. Am J Ind Med.
2016;59(11):1020–31. https://doi.org/10.1002/
thus reducing the risk of loss of pneumoperito- ajim.22614.
neum to the operating theater environment. These 3. Gatti JE, Bryant CJ, Noone RB, Murphy JB. The
trocars also have valves preventing gas leakage mutagenicity of electrocautery smoke. Plastic
whenever an instrument is passed through into Reconstr Surg. 1992;89(5):785–6. https://doi.
org/10.1097/00006534-199205000-00002.
the peritoneal cavity. Pneumoperitoneum should 4. Karjalainen M, Kontunen A, Saari S, et al. The char-
be maintained throughout the procedure at the acterisation of surgical smoke from various tissues
lowest possible pressure and decompressed and its implications for occupational safety. PLoS
Surgical Smoke: Risks and Mitigation Strategies 73
One. 2018;13(4):e0195274. https://doi.org/10.1371/ 12. Benson SM, Novak DA, Ogg MJ. Proper use of
journal.pone.0195274. surgical N95 respirators and surgical masks in
5. Liu Y, Song Y, Hu X, Yan L, Zhu X. Awareness of the OR. AORN J. 2013;97(4):457–70. https://doi.
surgical smoke hazards and enhancement of surgi- org/10.1016/j.aorn.2013.01.015.
cal smoke prevention among the gynaecologists. J 13. Fan JK-M, Chan FS-Y, Chu K-M. Surgical smoke.
Cancer. 2019;10(2):2788–99. https://doi.org/10.7150/ Asian J Surg. 2009;32(4):253–7. https://doi.
jca.31464. org/10.1016/s1015-9584(09)60403-6.
6. Yoshifumi T, Shigenobu M, Kazuto N, et al. 14. Gao S, Koehler RH, Yermakov M, Grinshpun
Mutagenicity of smoke condensates induced SA. Performance of facepiece respirators and surgical
by CO2-laser irradiation and electrocauteriza- masks against surgical smoke: simulated workplace
tion. Mutat Res. 1981;89(2):145–9. https://doi. protection factor study. Ann Occup Hyg. 2016;60:608–
org/10.1016/0165-1218(81)90120-8. 18. https://doi.org/10.1093/annhyg/mew006.
7. Sisler JD, Shaffer J, Soo J-C, et al. In vitro toxico- 15. Choi SH, Choi DH, Kang DH, et al. Activated car-
logical evaluation of surgical smoke from human tis- bon fibre filters could reduce the risk of surgical
sue. J Occup Med Toxicol. 2018;13(1):12. https://doi. smoke exposure during laparoscopic surgery: appli-
org/10.1186/s12995-018-0193-x. cation of volatile organic compounds. Surg Endosc.
8. Alp E, Bijl D, Bleichrodt R, Hansson B, Voss 2018;32(10):4290–8. https://doi.org/10.1007/
A. Surgical smoke and infection control. J Hosp s00464-018-6222-0.
Infect. 2006;62(1):1–5. https://doi.org/10.1016/j. 16. Mowbray NG, Ansell J, Horwood J, et al. Safe man-
jhin.2005.01.014. agement of surgical smoke in the age of COVID-19.
9. Lobraico RV, Schifano MJ, Brader KR. A retrospec- Br J Surg. 2020;107(11):1406–13. https://doi.
tive study on the hazards of the carbon dioxide laser org/10.1002/bjs.11679.
plume. J Laser Applic. 1998;1(1):6–8. https://doi. 17. Team RCSEC. Intercollegiate General Surgery
org/10.2351/1.4745215. Guidance on COVID-19 UPDATE. The Royal College
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on the peritoneal implantation of free intraperitoneal news/2020/march/intercollegiate-general-surgery-
colon cancer cells. Surg Endosc. 1996;10(8):809–12. guidance-on-covid-19-update. Accessed 11 July 2020.
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11. Schultz L. An analysis of surgical smoke plume compo-
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98. https://doi.org/10.1016/j.aorn.2013.07.020.
Part II
Anesthesia in Laparoscopic Surgery
Principles of Anesthesia
Emily Rose Nery
Introduction recovery, reducing the length of stay, and early

return to preoperative status by reducing surgical
The evolution of minimally invasive surgery in stress response is seen as a complementary
the last three decades led to better surgical expe- approach to minimally invasive surgery [3].
rience, improvements in instrumentation, and Established ERAS programs integrate several
application in a wide range of surgical procedures items among which short fasting time, periopera-
[1]. It has quickly emerged as the new gold stan- tive fluid optimization, multimodal pain manage-
dard versus traditional open surgical approaches. ment, early mobilization, PONV prophylaxis,
The advantages of laparoscopic surgery include and treatment [4] as elements that overlap with
reduced tissue trauma, reduced postoperative the laparoscopic technique.
opioid analgesic requirement, improved postop-
erative pulmonary function, early recovery, and
cost-effectiveness [2]. Physiologic Changes
In laparoscopic surgery, the principles of
anesthetic management centers around the inter- The greatest impact on cardiovascular, pul-
action of the following elements: (1) intraperi- monary, and renal physiology stems from the
toneal insufflation of carbon dioxide to create pneumoperitoneum, the choice of carbon diox-
a pneumoperitoneum, (2) the systemic effects ide (CO2) as insufflating gas, and the effects
of carbon dioxide absorption, (3) the extreme of patient positioning. Carbon dioxide is the
changes in patient positioning, and (4) patient- preferred gas because it is highly soluble in
related factors. blood, clears more rapidly, and is not combus-
The advent of enhanced recovery programs tible. The increase in intra-abdominal pressure
with their goal of accelerating postoperative (IAP) from CO2 insufflation exerts mechani-
cal and physiologic effects, while the systemic
absorption of CO2 produces hypercarbia and
acidosis.
E. R. Nery (*)
Department of Anesthesiology, The Medical City,
The determinants of cardiac output are sys-
Pasig, Philippines temic venous return and preload. Majority of
Acute and Critical Care Institute, The Medical City,
the venous blood that enters the right atrium
Pasig, Philippines comes from the inferior vena cava (IVC). At
Department of Anesthesiology and Perioperative
IAP = 7.5 mm Hg, compression of the splanch-
Medicine, Rizal Medical Center, Pasig, Philippines nic circulation diverts the blood centrally and
e-mail: ecnery@themedicalcity.com an early rise in cardiac output is observed [5].
https://doi.org/10.1007/978-981-19-3755-2_12
78 E. R. Nery
But as IAP continues to rise beyond 15 mm Anesthetic Management

Hg, mechanical compression of the IVC and
blood pooling in the lower extremities results in Preoperative Evaluation
decreased venous return and a decrease in car-
diac output [5]. Preoperative evaluation and preparation of
Neuroendocrine responses and aortic com- patients for laparoscopic surgery follow the same
pression results in increases in mean arterial guideline equivalent to any surgery. A medical
pressure (MAP) and systemic vascular resis- history and physical examination should be per-
tance (SVR). Reduction in cardiac output acti- formed for all patients. The American Society of
vates the renin-angiotensin system and release Anesthesiologists (ASA) classification aids in
of vasopressin resulting in an increase in stratifying patients based on their physiologic
MAP. Stimulation of the sympathetic nervous reserves. Keeping in mind the physiologic
system and release of catecholamines mediates derangements inherent with laparoscopy, further
the increase in SVR [6]. While vagal stimulation assessment of the patient’s medical condition
from abdominal distention and insertion of may be warranted.
Veress needle may result in bradyarrhythmias Generally, laparoscopic surgery has a lower
and cardiac arrest [7]. Measures to attenuate the cardiovascular risk compared with open tech-
vagal response include slower insufflation time, niques. However, an understanding of the physi-
lower IAP, and pharmacologic. ologic effects of the surgical technique that may
Cephalad displacement of the diaphragm increase the perioperative risk in specific patient
secondary to pneumoperitoneum may impact population is essential. Adequate patient prepara-
pulmonary mechanics. Diaphragmatic displace- tion, identification of risks, and anticipation of
ment reduce lung volumes, reduce lung compli- the hemodynamic and ventilatory effects together
ance, and increase airway pressures. The with a comprehensive anesthetic plan can miti-
resulting decrease in functional residual capac- gate the risk of adverse events and improve post-
ity (FRC) and atelectasis may lead to V/Q mis- operative recovery.
match [8]. Patients with cardiovascular diseases may not
Hypercarbia and acidosis as the result of CO2 tolerate the increases in preload (↑ RAP, PCWP)
absorption lead to cardiovascular and hemody- and afterload (↑ SVR) and a decrease in cardiac
namic consequences [9]. Hypercarbia is output (CO). Those with decreased myocardial
addressed by increasing minute ventilation to reserves may suffer decompensation brought
maintain normal end-tidal CO2. about by further reductions in cardiac output.
Extreme changes in patient positioning in While the risk of myocardial ischemia in laparo-
either a head-up (reverse Trendelenburg) or scopic surgery is low, it may be precipitated by
head-down (Trendelenburg) orientation affect increases in myocardial oxygen demand brought
cardiovascular and pulmonary functions. The about by increases in heart rate (HR), mean arterial
head-up position leads to venous pooling affect- pressure (MAP), and systemic vascular resistance
ing venous return to the heart. Catecholamines (SVR). Mitigating measures include optimization
are also elevated in a head-up position, increas- of fluid status preoperatively, appropriate medica-
ing SVR further reducing CO. The head-down tions including continuing beta-blockers and heart
position, on the other hand, moves the diaphragm failure medicine, close hemodynamic monitor-
and abdominal contents cephalad, reducing ing intraoperatively, avoidance of hypothermia,
pulmonary compliance and increasing airway keeping the IAP < 15 mm Hg, and adequate pain
pressures. The reverse Trendelenburg favors management [10]. Morbid obesity is associ-
pulmonary function, while the Trendelenburg ated with comorbidities including diabetes mel-
favors venous return. litus, hypertension, obstructive sleep apnea, and
Principles of Anesthesia 79
restrictive lung disease. Pneumoperitoneum dur- dences of coughing, laryngospasm, sore throat,
ing laparoscopy alters the respiratory mechanics and hoarseness.
more in morbidly obese patients compared with Pneumoperitoneum in laparoscopy may cause
patients of normal weight. Pulmonary compli- derangements of the cardiopulmonary function
ance is reduced whereas inspiratory resistance is and a lung-protective ventilation strategy using a
elevated requiring higher minute ventilation to combination of tidal volume of 6–8 ml/kg ideal
maintain normocarbia [11]. Perioperative man- body weight, a fraction of inspired oxygen (FiO2)
agement includes avoiding steep head-down posi- of 0.5 ml, application of PEEP and recruitment
tion, avoiding early extubation, and in some cases, maneuvers help improve lung mechanics and
extubation to CPAP/BIPAP. improve hypoxemia [13]. Controlled mechanical
ventilation with pressure or volume modes is
used to reduce peak inspiratory pressure and
Intraoperative Management manage hypercarbia during laparoscopy.
Neuromuscular blocking agents (NMBA)
General anesthesia with endotracheal intubation help facilitate endotracheal intubation, improve
and controlled mechanical ventilation is the most surgical conditions by increasing the compliance
common choice of anesthesia technique. Balanced of the abdomen and allow control of ventilation.
anesthesia employing either inhaled or intrave- The choice is guided by the drug’s pharmaco-
nous anesthetics is chosen based on anesthesiolo- logic profile and anticipated length of surgery.
gist’s preference, the pharmacologic profile of the Reversal of NMBAs is by metabolism or phar-
drugs, and the physiologic status of the patient. macologic (neostigmine and sugammadex).
A total intravenous anesthesia (TIVA) using a Quantitative evidence of adequate reversal must
propofol-based hypnotic has the added benefit of be confirmed with train-of-four monitor.
reducing postoperative nausea and vomiting. Perioperative fluid management is very com-
Airway management with a cuffed endotra- plex and clinically challenging. Hypervolemia
cheal tube prevents aspiration pneumonitis and is increases the incidence of edema, impairs gut
still the airway of choice for most laparoscopic motility, and impairs wound healing. At the other
surgeries. Carbon dioxide insufflation shifts the end of the spectrum, hypovolemia may worsen
diaphragm cephalad which increases airway hypotension, lead to oxygen mismatch, organ
pressure. This in turn increases the chance of air dysfunction, and lactic acidosis [14]. Static indi-
leaks, inadequate ventilation, and gastric insuf- cators of fluid balance like heart rate, central
flation that potentiates the risk of regurgitation venous pressure, and urine output are unreliable.
and aspiration. However, employing monitors for goal-directed
Several studies have compared the safety, effi- fluid therapy remains controversial in laparo-
cacy, and complication risks of supraglottic air- scopic surgery. The decision to use invasive and
way devices (SGA) with endotracheal tubes noninvasive monitors to guide fluid management
(ETT). SGAs were found to be clinically useful must be based on the patient’s condition and the
in laparoscopy [12]. Second-generation SGAs extent of surgery.
with ventilation tube and gastric access provide
higher oropharyngeal leak pressure than first- Monitoring
generation SGAs and reduce the risk of aspira- Placement of routine monitoring equipment fol-
tion. These factors make a SGA device a viable lows the basic standards of the ASA and includes
option for airway management with the added pulse oximetry, noninvasive blood pressure mon-
benefits of attenuated hemodynamic changes itoring, electrocardiography, temperature, and
compared with laryngoscopy and ETT as well as end-tidal carbon dioxide monitor. Additional
being well tolerated by patients with fewer inci- monitors are warranted based on the duration of
80 E. R. Nery
surgery, patient condition, and expected blood ostoperative Nausea and Vomiting
P
loss. (PONV)
PONV is one of the most distressing experience
Positioning for patients after surgery. Although laparoscopy
Care must be taken to ensure that bony promi- is identified as one risk factor for PONV, the lit-
nences and pressure points are well padded as in erature is far from robust. Several predictors of
any surgery to prevent injury and peripheral nerve risk of PONV in adults have been identified
damage. Extremes in patient position necessitate including (1) female gender, (2) history of motion
the application of non-slip padding and body sickness or PONV, (3) non-smoker, and (4) post-
restraints to secure the patient to the operating operative opioid use [16]. The risk increases with
table safely. Foot supports are employed in sur- the number of factors present. Current recom-
geries that require reverse Trendelenburg posi- mendation is a multimodal antiemetic therapy
tions, while shoulder supports placed laterally based on the patient’s level of risk using a combi-
at the acromioclavicular joint are used for steep nation of dexamethasone and 5-HT3 receptor
Trendelenburg positions. The head is rested on a antagonists. Additional antiemetic therapy may
foam pillow with the neck in a neutral position. be used for very high-risk patients or as a rescue
Arms are either tucked at the side or abducted to for intractable PONV [17].
less than 90 on padded arm boards depending on
the type of surgery and must be kept in a neutral
thumbs-up or supinated position. References
1. Leonard IE, Cunningham AJ. Anaesthetic consider-
ations for laparoscopic cholecystectomy. Best Pract
Postoperative Management Res Clin Anaesthesiol. 2002;16(1):1–20.
2. Keller DS, Delaney CP, et al. A national evaluation
Pain expectations should be discussed preoper- of clinical and economic outcomes in open ver-
atively. The sources of pain from laparoscopic sus laparoscopic colorectal surgery. Surg Endosc.
2016;30(10):4220–8.
surgery are both somatic and visceral and the 3. Ni X, Jia D, et al. Is the enhanced recovery after
degree of pain depends on the specific surgery surgery (ERAS) program effective and safe in lapa-
but is usually low to moderate. Evidence-based roscopic colorectal cancer surgery? a meta-analysis
pain management recommends a combination of randomized controlled trials. J Gastrointest Surg.
2019;23(7):1502–12.
of paracetamol, NSAID or cyclooxygenase-2- 4. Gustafsson UO, Scott MJ, et al. Guidelines for
specific inhibitor, surgical site local infiltration, perioperative care in elective colorectal sur-
and dexamethasone [15]. A procedure-specific, gery: Enhanced Recovery After Surgery (ERAS)
multimodal approach capitalizing on preemp- Society Recommendations: 2018. World J Surg.
2019;43(3):659–95.
tive analgesia and opioid-sparing techniques 5. Kitano Y, Takata M, et al. Influence of increased
improve outcomes by providing adequate abdominal pressure on steady-state cardiac perfor-
analgesia and reducing patient discomfort and mance. J Appl Physiol. 1999;86(5):1651–6.
adverse effects compared with a single opioid 6. Myre K, Rostrup M, et al. Plasma catecholamines and
haemodynamic changes during pneumoperitoneum.
technique. Acta Anaesthesiol Scand. 1998;42(3):343–7.
The advent of ultrasound-guided nerve blocks 7. Yong J, Hibbert P, et al. Bradycardia as an early warn-
expanded the possibilities for pain management ing sign for cardiac arrest during routine laparoscopic
in laparoscopic surgeries. Currently, several tech- surgery. Int J Qual Health Care. 2015;27(6):473–8.
8. Atkinson. Cardiovascular and ventilatory conse-
niques (i.e., transversus abdominis plane, para- quences. 703.
vertebral, and quadratus lumborum blocks) are 9. Cunningham AJ. Laparoscopic surgery—anesthetic
being explored with promising results. implications. Surg Endosc. 1994;8:1272–84.
10. Atkinson. Cardiovascular and ventilatory conse-
quences. 701–702.
Principles of Anesthesia 81
11. Sprung J, Whalley DG, et al. The impact of morbid 15. Barazanchi AWH, MacFater WS, et al. Evidence-
obesity, pneumoperitoneum, and posture on respira- based management of pain after laparoscopic cho-
tory system mechanics and oxygenation during lapa- lecystectomy: a PROSPECT review update. Br J
roscopy. Anesth Analg. 2002;94:1345–50. Anaesth. 2018;121(4):787–803.
12. Park SK, Ko G, et al. Comparison between supraglot- 16. Horn CC, Wallisch WJ, et al. Pathophysiological and
tic airway devices and endotracheal tubes in patients neurochemical mechanisms of postoperative nausea
undergoing laparoscopic surgery: a systemic review and vomiting. Eur J Pharmacol. 2014;722:55–66.
and meta-analysis. Medicine. 2016;95(33):e4598. 17. Gan TJ, Belani KG. Fourth consensus guidelines for
13. Valenza F, Chevallard G, et al. Management of the management of postoperative nausea and vomit-
mechanical ventilation during laparoscopic surgery. ing. Anesth Analg. 2020;131(2):411–48.
Best Pract Res Clin Anaesthesiol. 2010;24:227–41.
14. Rehm M, Hulde N, et al. State of the art in fluid and vol-
ume therapy. Anaesthesist. 2019;68(Supp1):S1–14.
Physiologic Considerations
in Laparoscopic Surgery
Alembert Lee-Ong
Introduction The absorption rate of CO2 is influenced by its

partial pressure gradient between the cavity and
MIS technique compared to the open technique is the blood, its diffusion coefficient, the surface
associated with substantial benefits for the patients, area of the cavity, and the perfusion of the walls of
attributable to less surgical trauma; however, this the cavity [2]. The CO2 absorbed is dissolved in
does not imply the absence of physiologic changes the blood and delivered to the lungs for excretion
when not anticipated may be deleterious. These by ventilation, while the majority combines with
physiologic alterations are triggered by a combi- water to form carbonic acid, which dissociates
nation of the following: the insufflation gas used, into hydrogen and bicarbonate. The hydrogen
the increase in intra-abdominal pressure (IAP), the ions complex with hemoglobin and the bicarbon-
extreme patient positioning during surgery, and ate diffuses into the plasma. These result in an
the effect of the surgery itself [1]. increase in arterial pCO2 and a fall in arterial pH.
The space insufflated with CO2 influences the
physiologic changes exerted by CO2 absorption.
Carbon Dioxide (CO2) Effect Intraperitoneal insufflation with CO2 is associated
with an initial rapid rise in pCO2 during the first
Carbon dioxide is the gas of choice used for insuf- 15 min and followed by plateau or second phase
flation in MIS, as it is nontoxic, nonflammable, of slower change [2]. Extraperitoneal insuffla-
rapidly soluble in blood, easily eliminated by the tion shows a significantly faster rise in pCO2 and
lungs, and relatively inexpensive [1]. Since CO2 is tends to persist into the postoperative period [3].
a normal product of cellular metabolism, at physi- The magnitude of the rise in pCO2 was not signifi-
ological levels is nontoxic and an efficient means cantly different between extra- and intraperitoneal
for its elimination is inherent in humans. insufflation [2]. The faster rate seen in extraperi-
toneal insufflation may be due to concentrated
A. Lee-Ong (*) absorption, vascularity of the extraperitoneal
Department of Surgery, Manila Doctors Hospital, space, a faster diffusion in the extraperitoneal cav-
Manila, Philippines ity, or a combination of these factors.
Philippine Center for Advanced Surgery, Mild hypercarbia (pCO2 of 45–50 mm Hg) has
San Juan, Philippines minimal effect on hemodynamics; however,
Department of Surgery, Cardinal Santos Medical moderate to severe hypercarbia have both direct
Center, San Juan, Philippines and indirect effects on the cardiovascular system:
Department of Surgery, Quirino Memorial Center, direct effects include myocardial depression and
Quezon City, Philippines vasodilatation, while indirect effects are brought
https://doi.org/10.1007/978-981-19-3755-2_13
84 A. Lee-Ong
about by catecholamine release eventually caus-

ing increase myocardial oxygen consumption
[2]. While most healthy individuals will not be
significantly affected by CO2 elevation and can
be corrected with moderate hyperventilation;
those with cardiorespiratory compromise may
not respond similarly and will need careful peri-
operative monitoring.
Insufflation with CO2 results in a blunted
immune response compared to open procedures.
Acute-phase reactant (C-reactive protein) and
cytokines (interleukin-6 and tumor necrosis Fig. 1 Effects of increased intra-abdominal pressure on
factor-alpha) produced in response to tissue injury organs
are likewise reduced in the presence of CO2 [4].
elevated however the CO starts to decrease below
the baseline [6]. The drop in CO is attributed to
Pneumoperitoneum/Increase the decreased venous return caused by IVC com-
Intra-abdominal Pressure Effect pression and the pooling of the venous blood in
the lower extremities. There is also an increase in
Insufflation of the abdominal cavity results in afterload with an increase in IAP, seen as an
shifting the abdominal wall outwards and the increase in mean arterial pressure (MAP) and sys-
diaphragm upwards, resulting in an increase in temic vascular resistance (SVR) that contribute to
intra-abdominal pressure (IAP) and reduction of the decrease in CO. The compression of the renal
thoracic volume, respectively. Respiratory compli- vasculature reduces renal blood flow stimulating
ance is reduced by 50% when the peritoneal cavity the release of aldosterone and renin that contrib-
is insufflated to a pressure of 15 mm Hg [1, 5]. ute to the increase in MAP, and the release of
Pulmonary functions reduced with the decrease atrial natriuretic peptide cortisol, epinephrine,
in lung compliance include forced expiratory vol- norepinephrine, and vasopressin.
ume in the first second (FEV1), functional resid- The hemodynamic changes will immediately
ual capacity (FRC), total lung capacity, and vital return to baseline levels after desufflation among
capacity (VC) [1]; these changes can predispose healthy individuals, in those with cardiovascular
to the development of ventilation-perfusion mis- disease these can persist for at least 65 min.
match, leading to hypoxemia. Increasing the venti- Those with cardiovascular compromise may
latory rate is necessary to promote ventilation and experience an elevation in cardiac index, ejection
maintain pCO2 at or near-normal levels (Fig. 1). fraction, heart rate, left ventricular stroke work
Hemodynamic changes seen with pneumo- index, and decrease in SVR; with 20% of these
peritoneum are the result of mechanical and neu- patients developing heart failure within 3 h after
rohormonal responses. The increased IAP caused the MIS procedure [7]. Though laparoscopy
by pneumoperitoneum produces vascular com- appears to be safe in patients with cardiac dis-
pression of the inferior vena cava (IVC), aorta, ease, it will require special attention and addi-
splanchnic vasculature, and renal vasculature; this tional intraoperative monitoring.
shifts the peripheral vascular volume to the cen-
tral venous compartment, causing an initial
increase in venous return [5]. A biphasic response Patient Positioning Effects
is seen with an increase in the right atrial pressure
(RAP), left atrial pressure (LAP), and cardiac out- Placing the patient in Trendelenburg or reverse
put (CO) at 7.5 mm Hg IAP; as the IAP increases Trendelenburg position facilitates optimal visual-
beyond 15 mm Hg, both the RAP and LAP remain ization of the surgical field in the lower abdomen
Physiologic Considerations in Laparoscopic Surgery 85
or pelvis and the upper abdomen, respectively. vigilant perioperative monitoring to mitigate the
Shifting from supine to Trendelenburg position adverse effects.
displaces the diaphragm and abdominal contents
cephalad. This enhances the pulmonary compro-
mise associated with CO2 insufflation, reduction References
of pulmonary compliance, and increase peak air-
way pressure. It however mitigates the effect on 1. Hasukic S. CO2-pneumoperitoneum in laparoscopic
surgery: pathophysiologic effects and clinical signifi-
the hemodynamic changes with increased venous cance. World J Laparosc Surg. 2014;7(1):33–40.
return and pulmonary capillary wedge pressure 2. Wright DM, Serpell MG, Baxter JN, et al. Effect of
which minimize the decline in CO with an extraperitoneal carbon dioxide insufflation on intra-
increase in IAP [5]. The reverse Trendelenburg operative blood gas and hemodynamic changes. Surg
Endosc. 1995;9(11):1169–72.
position will generate positive ventilatory effects3. Demiroluk S, Salihoglu Z, Bakan M, et al. Effects
and negative hemodynamic effects. of intraperitoneal and extraperitoneal carbon diox-
ide insufflation on blood gases during the periop-
erative period. J Laparoendosc Adv Surg Tech A.
2004;14(4):219–22.
Summary 4. Grabowski JE, Talamini MA. Physiological
effects of pneumoperitoneum. J Gastrointest Surg.
The MIS technique imposes physiologic changes 2009;13(5):1009–16.
outside of that caused by anesthesia and the 5. Sharma KC, Brandstetter RD, Brensilver JM, et al.
Cardiopulmonary physiology and pathophysiology
nature of surgery; these factors include CO2 use, as a consequence of laparoscopic surgery. Chest.
increase IAP, and patient positioning. These pul- 1996;110(3):810–5.
monary and cardiovascular changes are generally 6. Atkinson TM, Giraud GD, Togioka BM, et al.
well tolerated by the healthy patient during the Cardiovascular and ventilatory consequences of lapa-
roscopic surgery. Circulation. 2017;135(7):700–10.
procedure and recover immediately afterward. 7. Odeberg-Wernerman S. Laparoscopic surgery--effects
Cognizance of intraoperative and sustained on circulatory and respiratory physiology: an over-
effects afterward among patients with cardio- view. Eur J Surg Suppl. 2000;585:4–11.
pulmonary impairment would emphasize the
need for thorough preoperative preparation and
Part III
Diagnostic Laparoscopy
Staging Laparoscopy
for Intra-Abdominal Carcinoma
Michael M. Lawenko
Introduction General Indications [2]
Diagnostic laparoscopy is used for the diagnosis 1. Identification of occult metastatic disease or
of intra-abdominal pathologies due to its capabil- unsuspected locally advanced disease in
ity to directly visualize intra-abdominal organs patients with resectable disease based on pre-
with the opportunity for gathering tissue biopsy, operative imaging.
fluid aspiration, and tissue cultures [1] Its appli- 2. Assessment prior to administration of neoad-
cation for the staging of intra-abdominal cancers juvant chemoradiation.
is known as staging laparoscopy. 3. Selection of palliative treatments in patients
with locally advanced disease without evi-
dence of metastatic disease on preoperative
Instruments imaging.
• 12 mm trocar
• 5 mm trocar × 2 General Contraindications
• 30° laparoscope Atraumatic bowel graspers × 2
• Maryland forceps. 1. Verified metastatic disease.
• Laparoscopic shears. 2. Inability to tolerate pneumoperitoneum or
• Suction-Irrigation cannula. general anesthesia.
• Punch biopsy forceps. 3. Multiple adhesions/prior operations.
• Laparoscopic aspiration cannula. 4. Intra-abdominal carcinoma complicated by
obstruction, hemorrhage, or perforation in
need of palliative surgery.
Surgical Technique
Under general anesthesia, a 10 mm umbilical

incision is made for insertion of the Hasson’s tro-
car with stay sutures to secure that trocar. A pneu-
M. M. Lawenko (*) moperitoneum at 12 mm Hg on medium flow
De La Salle Medical and Health Sciences Institute,
Dasmarinas City, Philippines (10–15 L/min) is created. The 30° telescope is
e-mail: mmlawenko@dlshi.edu.ph then inserted through the 12 mm trocar and an
https://doi.org/10.1007/978-981-19-3755-2_14
90 M. M. Lawenko
initial exploration of the abdominal cavity is per- bleeding, monopolar or bipolar hemostasis can
formed to evaluate for peritoneal as well as liver be used. Aspiration of ascitic fluid can be
metastases. Port placement of the working tro- achieved by letting the fluid gravitate using
cars will now depend on the location of the proper patient positioning and retraction of the
pathology. The general rule is to apply the tech- bowels away from the field. An aspiration can-
nique of triangulating the working ports in rela- nula with a 10 mm syringe attached at its end is
tion to the camera and the suspected pathology. A inserted for getting a sample of fluid for cell
minimum of two trocars is advised, but additional cytology.
trocars are deemed appropriate if needed. The Depending on the type of carcinoma, different
size of the working trocars is variable depending maneuvers can be done to visualize the pathol-
on the instruments that you will use. Two 5 mm ogy. These will be discussed in the succeeding
trocars would be sufficient to fit most instru- chapters in more detail.
ments, being liberal to changing to a 10 mm
working trocar as the need arises.
If no intra-abdominal metastasis is noted, References
definitive treatment can commence as planned.
In peritoneal carcinomatosis, biopsies can be 1. Ramshaw BJ, Esartia P, Mason EM, et al. Laparoscopy
for diagnosis and staging of malignancy. Semin Surg
performed by using Maryland forceps to pull Oncol. 1999;16:279–83.
down on the peritoneum where an area of metas- 2. SAGES guidelines for diagnostic laparoscopy.
tasis is located and using the laparoscopic shears https://www.sages.org/publications/guidelines/
to cut that peritoneum together with the pathol- guidelines-for-diagnostic-laparoscopy/
ogy. Minimal bleeding is usually encountered
here which will eventually stop. For continuous
Diagnostic Laparoscopy
Michael M. Lawenko
Introduction General Technique for Diagnostic

Laparoscopy
Diagnostic laparoscopy is used in endoscopic
surgery for the diagnosis of intra-abdominal Under general anesthesia, a 10 mm umbilical
pathologies. This technique has the capability for incision is made for insertion of the Hasson’s tro-
directly visualizing intra-abdominal organs with car with stay sutures to secure that trocar. A pneu-
the opportunity for gathering tissue biopsy, fluid moperitoneum at 12 mm Hg on medium flow
aspiration, and tissue cultures. This procedure (10–15 L/min) is created. The 30° telescope is
has the capability to aid other possible interven- then inserted through the 12 mm trocar and an
tional alternatives. initial exploration of the abdominal cavity is per-
There are several situations in which the role formed. Port placement of the working trocars
of diagnostic laparoscopy (DL) is useful in reduc- will now depend on the location of the pathology.
ing the number of unnecessary laparotomies. The general rule is to apply the technique of tri-
Staging laparoscopy can be done for intra- angulating the working ports in relation to the
abdominal cancer. Its application in the acute camera and the suspected pathology. A minimum
abdominal condition is also common. There is of two trocars is advised, but additional trocars
also DL for chronic conditions, such as infection, are deemed appropriate if needed. The size of the
pelvic pain, cirrhosis, and cryptorchidism. working trocars is variable depending on the
instruments that you will use. Two 5 mm trocars
would be sufficient to fit most instruments, being
Instruments liberal to changing to a 10 mm working trocar as
the need arises.
• 12 mm trocar If a known pathology is suspected, for exam-
• 5 mm trocar × 2. ple, acute appendicitis. Upon insertion of the
• 30° laparoscope camera, a limited diagnostic laparoscopy is done
• Atraumatic bowel graspers × 2. around the abdominal cavity before focusing on
the right lower quadrant. One working trocar is
placed initially at the left lower quadrant for a
bowel grasper to assist in exposing the appendix.
Upon confirmation of acute appendicitis, the next
M. M. Lawenko (*)
De La Salle Medical and Health Sciences Institute,
working trocar can be placed on area of your
Dasmarinas City, Philippines preference as long as proper triangulation of the
e-mail: mmlawenko@dlshsi.edu.ph instruments in relation to the pathology is
https://doi.org/10.1007/978-981-19-3755-2_15
92 M. M. Lawenko
a b
Fig. 1 (a) Intra-abdominal milliary tuberculosis during diagnostic laparoscopy with (b) biopsy
observed. If another pathology is to be suspected denum down to the sigmoid using both bowel
(and not appendicitis), then a formal diagnostic graspers to run the bowels. If needed, the greater
laparoscopy can commence. sac of the stomach is opened to visualize the
For the above example, in performing a for- pancreas retroperitoneally.
mal diagnostic laparoscopy, a second working Specimen collection can be accomplished in
trocar is placed at the right lower quadrant and various ways. For pedunculated nodules on the
the patient is placed in a reverse Trendelenburg peritoneum or abdominal organs, a sharp dissec-
position. Inspection of the right upper quadrant tion of the nodules can be achieved, followed by
by visualizing the liver and the subdiaphrag- appropriate hemostasis (Fig. 1). For evacuation
matic area is done, going down to the subhepatic and examination of fluids like ascites and puss,
area to where the gallbladder and the extrahe- needle aspiration instruments connected to
patic biliary tree are located. The left upper syringes can be done.
quadrant is visualized by inspecting the anterior
wall of the stomach, gastroesophageal junction,
and splenic area. The patient is then placed in the Further Reading
Trendelenburg position to examine the pelvic
area. Bowels are moved cephalad in order to Ramshaw BJ, Esartia P, Mason EM, et al. Laparoscopy
for diagnosis and staging of malignancy. Semin Surg
visualize the posterior wall of the urinary blad- Oncol. 1999;16:279–83.
der, sigmoid, and rectum, in addition to the SAGES guidelines for diagnostic laparoscopy.
uterus, ovaries, and fallopian tubes in females. https://www.sages.org/publications/guidelines/
Once the patient is returned to the supine posi- guidelines-for-diagnostic-laparoscopy/
tion, the bowels are now inspected from the duo-
Part IV
Emergency Laparoscopy
Perforated Ulcer Treatment
Mika Yamamoto and Kiyotaka Imamura
The perforated ulcers were treated by open gas- Indications for Operation
trectomy or simple suture until 1937 then Graham
introduced the method using a free omental graft, • Perforated ulcer with no evidence of sponta-
which is called the “Graham patch procedure” neous seal.
[1]. This procedure has long been a golden stan-
dard of surgical treatment for perforated peptic
ulcers. The idea of laparoscopic treatment had Indications for Nonoperative
arisen in the 1990s, and the comparison of superi- Management
ority between laparoscopy and open surgery has
long been discussed [2]. • Clinically stable, without signs and symptoms
Recently reported meta-analysis had shown the of sepsis, and with good radiologic evidence
significance of laparoscopic repair over the open that the perforation has sealed.
repair for postoperative pain in the first 24 h and • Low risk (Boey score* of 0,1).
postoperative wound infection, and equivalence of
multiple clinical outcomes [3]. In addition, explor- *Boey score: shock on admission, ASA grade
ative laparoscopy will be useful to gain more III–IV, symptom duration(>24 h) [4]. The maxi-
information about the perforation site and decide mum score is 3, which is indicated high surgical
to move on to laparoscopic repair or switch to risk.
open repair. Therefore, in a facility where there is
a surgeon that is well trained in the laparoscopic
procedure, laparoscopic repair is a better choice Contraindications for Laparoscopic
for the patient. Repair
• High-risk patient (Boey score of 3).

• Clinical evidence of concomitant bleeding ulcer.
• Previous abdominal surgery (relative).
M. Yamamoto
Department of Surgery, Teine Keijinkai Hospital,
Sapporo, Japan Preoperative Assessment
K. Imamura (*)
Minimally Invasive Surgery Center, Yotsuya Medical • Fluid resuscitation.
Cube, Tokyo, Japan • Preoperative antibiotics (cover gram-
e-mail: k-imamura@mcube.jp
negatives, anaerobes, mouth flora, and fungi).
https://doi.org/10.1007/978-981-19-3755-2_16
96 M. Yamamoto and K. Imamura
Surgical Technique
Identification of the Site

of Perforation
• Insert camera and the rest of the trocars in

Assistant place. Pneumoperitoneum is established and
maintained 10–12 mm Hg. Change the
patient’s position to reverse Trendelenburg
position and retract the liver to the cranial side
to expose the stomach and duodenum.
• Gently investigate the organs and look for the
Operator perforation site. Bacteriologic and fungal cul-
tures are taken. A biopsy is recommended to
perform for gastric ulcer perforation since
malignancy can be occasionally seen.
Fig. 1 OT setup and patient position • Even in the case of perforated gastric cancer, a
two-stage procedure should be performed in
• Intravenous PPI. most cases, consisting of suture closure of the
• Kept NPO and insertion of nasogastric (NG) perforation followed by a second-stage gas-
tube. trectomy [5].
• Adequate analgesics.
• Prophylactic anticoagulation.
Peritoneal Washing
OT Setup and Patient’s Position • Start with exploring the entire abdomen and
removing purulent collections and gastric/
• Patient is placed in the modified lithotomy bowel contents using suction to gain proper
position (Lloyd-Davies). field of view. Change the patient’s position to
• Surgeon stands between the legs of the patient. Trendelenburg position when exploring the
• Assistant stands on the left side of the patient. pelvic cavity. If the patient has suffered more
• Monitor is positioned above the patient’s right than 24 h after the onset, some fibrin
shoulder (Fig. 1). formation may be seen throughout the entire
abdomen.
• Be sure to conduct lavage enough so that the
Instrumentations Required omentum is clean without any pleural collections,
gastric/bowel contents, or fibrin before moving on
• 10 mm 30° laparoscope to coverage of the perforation with omentum.
• Scissors.
• Grasper.
• Needle holder. Closure of the Perforation
• Suction device.
• 3–0 absorbable suture needle Method of closure depends on the size of the
• 10 mm periumbilical trocar perforation;
• Two 5 mm trocars are positioned on either <1 cm: closure by interrupted sutures cov-
side along the midclavicular line at the level of ered with a pedicled omentum on top of the
the umbilicus. repair (Cellan-Jones repair [6]).
• One 5 mm trocar at the subxiphoid region is Applicate standard stitches with 3–0 absorb-
placed for retraction of liver or gallbladder. able sutures to close the perforation. When pull-
Perforated Ulcer Treatment 97
Fig. 2 Perforated ulcer with full-thickness wall suturing
Fig. 3 The sutures are tied using the intracorporeal Fig. 4 Omentum is brought up to the site of perforation to
technique ensure adequate length without tension. The omentum was
fixed with the falciform ligament to prevent dislodging
ing the omentum to cover the suture line, be sure

to avoid any tension. Do 3–4 additional stitches
to fix the omentum to the suture line. The last to suture, stuffing the omentum into the perfora-
procedure may be omitted; some studies which tion would be enough (Fig. 4).
compared the sutureless onlay omental patch >2 cm: If the perforation size is more than
method with sutured omental patch method 2 cm, it may be difficult to proceed graham patch
showed that either group never had postoperative closure. The operator should consider converting
leaks, and the former method had significantly to laparotomy.
shorter operative time and length of stay [7].
Perforated duodenal ulcer repair is done by
placing sutures through the full thickness of the After Closure
bowel wall with 3–0 absorbable suture (Figs. 2
and 3). After the perforation is properly covered, irrigate
1–2 cm: plugging the perforation with a the peritoneal cavity with at least 5 l of warm
free omental plug (Graham patch [1]). saline to wash off the impurities. To confirm the
If the perforation is 1 ~ 2 cm, the standard closure is watertight, instillation of intragastric air
stitch may give too much tension to the suture or methylene blue via the NG tube is useful. Drains
line. Therefore, the operator should skip the stan- are optional; however, there is no evidence to sup-
dard suture process and directly move on to cov- port their routine use. Remove trocars one after
ering and fixing the omentum to the perforation. another and be sure that there is no active hemor-
If the perforation is too big or damaged too much rhage of trocar sites. Close the skin with sutures.
98 M. Yamamoto and K. Imamura
Complications and Management References
• Leakage: repeat laparoscopy and rerepair lapa- 1. Graham RR. The treatment of perforated duodenal
ulcers. Surg Gyecol Obstet. 1937;64:235–8.
roscopically or convert to an open procedure. 2. Lau H. Laparoscopic repair of perforated peptic ulcer:
• Intra-abdominal abscess: percutaneous a meta-analysis. Surg Endosc. 2004;18:1013–21.
drainage. 3. Cirocchi R, et al. Meta-analysis of perioperative out-
• Intestinal obstruction. comes of acute laparoscopic versus open repair of per-
forated gastroduodenal ulcers. J Trauma Acute Care
Surg. 2018;85:417–25.
4. Boey J, et al. Risk stratification in perforated duodenal
Postoperative Care ulcers. A prospective validation of predictive factors.
Ann Surg. 1987;205:22–6.
5. Mouly C, et al. Therapeutic management of perforated
• NG tube is removed after 24 h when the resid- gastro-duodenal ulcer: literature review. J Visc Surg.
ual gastric aspirates are minimal. 2013;150:333–40.
• Oral intake is commenced once there is a 6. Cellan-Jones CJ. A rapid method of treatment in per-
return of bowel function. forated duodenal ulcer. Br Med J. 1929;1:1076–7.
7. Wang YC, et al. Sutureless onlay omental patch for the
• PPI. laparoscopic repair of perforated peptic ulcers. World
• Antibiotics. J Surg. 2014;38:1917–21.
• Upper endoscopy is performed 6–8 weeks
later to check H.pylori status and to assess for
healing in gastric ulcer perforation.
Laparoscopic Appendectomy
Michael M. Lawenko and Eva Lourdes Sta Clara
Introduction form in patients with perforated appendicitis,

but it is dependent on the surgeon’s expertise. It
Appendicitis is one of the most common causes offers lesser wound contamination during opera-
of a surgical abdomen. In 1894, McBurney per- tion and direct visualization during peritoneal
formed a new technique in treating appendicitis, washing.
which eventually became the gold standard for Another advantage of laparoscopy is the visu-
acute appendicitis [1]. However, in 1980, Kurt alization of the abdominal cavity to rule out other
Semm, a gynecologist from Switzerland per- pathologies and address them simultaneously. It
formed the first laparoscopic appendectomy [2]. is also preferable in women for cosmetic
The laparoscopic approach has several advan- reasons.
tages over the open appendectomy like lesser
postoperative pain, faster recovery, fewer wound
infections, and lesser incidence of adhesions. In Indications
addition, the complication rates were compa-
rable in laparoscopic and open appendectomy. • Any patient with signs and symptoms of acute
Laparoscopic appendectomy is also safe to per- appendicitis.
• Patient who are fit for general anesthesia.
M. M. Lawenko
De La Salle Medical and Health Sciences Institute, Contraindications
Dasmarinas City, Philippines
E. L. Sta Clara (*) • Severely septic with generalized peritonitis.
Training Officer (UMIST) and Training Committee,
• Severe pulmonary disease in whom carbon
Center, Manila, Philippines dioxide pneumoperitoneum may exacerbate
their condition.
Manila, Philippines • Hemodynamic instability.
• Patient not fit for general anesthesia.
Department of Surgery, Asian Hospital Medical
Center, Manila, Philippines • Advanced stage of pregnancy wherein the
intra-abdominal working space would be
Department of Surgery, University of Perpetual Help
Dalta Medical Center, Manila, Philippines suboptimal.

https://doi.org/10.1007/978-981-19-3755-2_17
100 M. M. Lawenko and E. L. Sta Clara
Preoperative Preparation Surgical Technique
• In female patients, an adequate menstrual his- The patient is under general anesthesia. The
tory and a pregnancy test. 10 mm port is inserted at the umbilicus using
• The minimum ancillary diagnostic test would Hasson’s technique and pneumoperitoneum is cre-
be a complete blood count and urinalysis. ated with CO2 pressure at 12 mmHg and flow rate
• CT scan may be warranted if the physical at medium or 20 L/min. A 5 mm port is then placed
examination and laboratories are equivocal. at the left lower quadrant and another 5 mm trocar
• Adequate intravenous hydration. is inserted at the suprapubic area under direct
• Prophylactic intravenous antibiotics with cov- vision to avoid any injury to any intrabdominal
erage for gram-negative and anaerobes. organs and vessels. A limited diagnostic laparos-
• Insertion of a urinary catheter to decompress copy is then done to exclude other pathologies.
the urinary bladder and minimize injury to it The appendix is identified by locating the
and allow for a bigger working space. cecum and tracing the taenia coli to the base of
• Informed consent with the potential to convert the appendix. Careful dissection is done if there
to an open procedure. are adhesions between the appendix and the sur-
rounding organs to avoid iatrogenic injury to the
bowels. Once the appendix is freed, this is then
OT Setup grasped then the mesoappendix is isolated by
using either one of the following:
The patient is in supine position in a Trendelenburg
position with the right side up to expose the right 1. Monopolar hook with diathermy dissection to
lower quadrant. The anesthesiologist and the isolate the artery.
anesthesia machine are at the patient’s head 2. Maryland dissector to bluntly isolate the artery.
(Fig. 1). The surgeon stands on the left side of the
patient opposite the appendix and the assistant Then the appendiceal artery is isolated and
stands at the right side of the surgeon. The video ligated using the following techniques:
monitor is positioned directly across the surgeon
at the right side of the patient. 1. Clip application using either small polymer or
titanium clips.
2. Bipolar vessel sealing (Fig. 2).
Fig. 1 OT setup Fig. 2 Vessel sealing

Laparoscopic Appendectomy 101
3. Ultrasonic vessel sealing for a small artery diceal mucosa on the stump is suctioned to make
less than 8 mm in size. sure that no fecalith remains and is burned with
bipolar energy to prevent the rare incidence of
The sealed artery can be cut using laparo- mucocele formation [5].
scopic shears or the included cutter in the Inspection of the stump and nearby surround-
advanced bipolar instruments. As with open ing area for fecal soilage, bleeding and bowel
appendectomy, the base of the appendix must be perforation is done. Suction is used for pooled
exposed completely and should be devoid of fat clotted blood and a few purulent materials.
in preparation for its ligation via the following Copious use of lavage is optional depending on
techniques: the presence of fecal soilage.
A sterile 10 × 5 cm plastic bag with a 35 cm
1. Simple suture ligation via intracorporeal nonabsorbable suture with a Roeder’s knot attached
suturing with a 2–0 braided suture on a round is placed in the umbilical port. The appendix is
half circle needle with two sutures on the placed in the bag, closed and extracted together at
patient side and one on the specimen side [3]. the umbilical port. This is done to decrease the inci-
2. Simple suture ligation via extracorporeal knot dence of infection at the umbilical incision [6].
tying of a 2–0 braided suture in creating a Alternative options can be the following:
loop ligation around the base of the appendix.
Applying 2 sutures on the patient side and one 1. The appendix is extracted from the abdo-
on the specimen side. men with the use of a condom, which is
3. Commercially available preformed suture inserted at the umbilical port. The appendix
loops (i.e., Endoloop™, Johnson & Johnson, is placed inside the condom and then tele-
USA) of a 2–0 braided suture in creating a scoped into the 10 mm port as the camera is
loop ligation around the base of the appendix. pulled out.
Applying two sutures on the patient side and 2. Use of a commercially available specimen
one on the specimen side (Fig. 3). bag which is inserted through the umbilical
4. Plastic clips (i.e., hem-o-lok™, Teleflex port. A 5 mm scope is placed in the left lower
Medical, USA) with two clips at the patient quadrant trocar while a bowel grasper is in
side and one at the specimen side [4]. the suprapubic port to assist in placing the
specimen in the bag. The bag is closed and
The ligated appendiceal base can now be cut retracted under direct vision together with
using the laparoscopic shears (Fig. 4). The appen- the trocar.
Fig. 3 Endoloop for ligation at the base of the appendix Fig. 4 Cutting the appendiceal base with shears
102 M. M. Lawenko and E. L. Sta Clara
3. If the appendix is thin (<1 cm) and not grossly Late complications include the following: inci-
purulent, a 5 mm scope is placed at the left sional hernia, stump appendicitis, and small bowel
lower quadrant while a bowel grasper at the obstruction due to postoperative adhesions.
suprapubic trocar feeds the specimen to the
grasper in the umbilical port for direct with-
drawal of the specimen. Post-op Care
Peritoneal lavage can be done if needed. A Patient is advised to ambulate once fully awake
closed suction drain is inserted in cases of perfo- and with adequate pain control. Diet is pro-
rated appendix. After extracting the specimen, gressed as tolerated and the patient is expected to
desufflation is done together with direct visual- be discharged on the first postoperative day for
ization through a scope in the umbilicus of the uncomplicated appendicitis.
working trocars to check for port site bleeding. Patient is then seen 1 week after for follow up.
Appropriate hemostasis is achieved prior to a fig-
ure of eight sutures with a 2–0 braided, absorb-
able suture at the fascial level of the umbilical References
incision. Subdermal interrupted skin closure with
4–0, monofilament, absorbable sutures are done 1. Mcburney. The incision made in the abdominal wall
in cases of appendicitis, with a description of a new
to close the skin incisions. Film dressings are method of operating. Ann Surg. 1894;20(1):38.
applied to the incision sites. 2. Semm K. Endoscopic appendectomy. Endoscopy.
1983;15(02):59–64.
3. Sayyadinia M, Hamadiyan H, Mokaripoor S, et al.
Comparing the complications of purse-string and
Complications and Management simple ligation of appendix stump in appendectomy:
a randomized clinical trial. Int J Med Res Health Sci.
The most common postoperative complication 2016;5(10):55–60.
in laparoscopic appendectomy is wound infec- 4. Abou-Sheishaa MS, Negm A, Abdelhalim M, et al.
Ligation versus clipping of the appendicular stump in
tion, which can be treated by antibiotics and/or laparoscopic appendectomy: a randomized controlled
drainage. However, compared to open appen- trial. Ann Emerg Surg. 2018;3(1):1029.
dectomy, this is markedly lower with a rate of 5. El Ajmi M, Rebai W, Safta ZB. Mucocele of appendi-
less than 2%. ceal stump—an atypical presentation and a diagnostic
dilemma. Acta Chirurgica Belgica. 2009;109(3):414–5.
Other complications which might occur is 6. Fields A, Lu P, et al. Does retrieval bag use during lap-
intra-abdominal abscess, which can be managed aroscopic appendectomy reduce postoperative infec-
by percutaneous drainage. tion? Surgery. 2019;165(5):953–7.
Meckel’s Diverticula
Introduction ulectomy with endostaplers, wedge or segmental

resection with extracorporeal or intracorporeal
Meckel’s diverticulum is one of the most com- anastomosis. Simple diverticulectomy is not
mon congenital anomalies of the small intes- advised if the base is broad and/or the diver-
tine, which resulted from the incomplete ticulum is noticeably short because of a risk
obliteration of the vitelline duct during embryo- of leaving behind heterotropic tissue [2]. Thus,
genesis. It is usually located at the terminal segmental resection followed by anastomosis is
ileum 45–90 cm proximal to the ileocecal valve preferable to diverticulectomy and wedge resec-
on its antimesenteric border. Almost half of the tion or tangential mechanical stapling because of
patients with this anomaly have ectopic gastric the risk of leaving behind abnormal heterotropic
or pancreatic mucosa, which might cause some mucosa [3]. Laparoscopic surgery compared to
complications [1]. open laparotomy has equivalent outcomes [4].
Patients with Meckel’s diverticulum are However, the choice of surgical approach still
usually asymptomatic and are commonly diag- depends on the patient’s condition, surgeon’s
nosed as an incidental finding. However, life expertise, and the availability of laparoscopic
threatening complications might occur like instruments.
bleeding, inflammation, intestinal obstruction,
and perforation.
Treatment of symptomatic Meckel’s diver- Indications
ticulum is definitive surgery either via diver-
ticulectomy, wedge or segmental resection. • Symptomatic patients with Meckel’s
Laparoscopically, it can be managed by divertic- diverticulum.
• Patient fit for general anesthesia.
E. L. Sta Clara (*)
Training officer (UMIST) and Training Committee,
Department of Surgery, Cardinal Santos Medical Contraindications
Department of Surgery, Rizal Medical Center, • Severe pulmonary disease in whom carbon
Manila, Philippines
dioxide pneumoperitoneum may exacerbate
Department of Surgery, Asian Hospital Medical their condition.
• Hemodynamic instability.
Department of Surgery, University of Perpetual Help • Patient not fit for general anesthesia.
Dalta Medical Center, Manila, Philippines

https://doi.org/10.1007/978-981-19-3755-2_18
104 E. L. Sta Clara
Preoperative Preparation
• Fluid resuscitation.
• Blood transfusion (if needed for bleeding
Meckel’s diverticulum).
• Correction of electrolyte imbalances simulta-
neously with hydration especially for Meckel’s
diverticulum which initially presented as an
obstruction.
• Prophylactic intravenous antibiotics with cov-
erage for gram negative and anaerobes.
Meckel’s diverticulum is difficult to diag-

nose. It usually mimics other abdominal
pathologies like appendicitis and is usually
confirmed only during laparotomy. Some
imaging studies might help in its diagnosis like Fig. 1 OT setup
technetium pertechnetate/Meckel’s scan, CT
scan, colonoscopy, or wireless capsule endos-
copy but they yield a high false-negative result Patient and Surgical Team
[5]. Therefore, its diagnosis requires a high Positioning
degree of suspicion as the preoperative clinical
and investigational diagnosis is difficult to be Patient is in supine position in a Trendelenburg
made with accuracy [6]. position with the right side slightly up to expose
the right lower quadrant. The anesthesiologist
and the anesthesia machine are at the patient’s
Operating Theater Setup head. The surgeon stands on the left side of the
patient and the assistant stands on the right side
Instruments of the surgeon. The video monitor is positioned
directly across the surgeon on the right side of the
• 10 mm 30° angled laparoscope patient (Fig. 1)
• Trocars.
• 10 mm optical or Hasson’s trocar
• 12 mm trocar Surgical Technique
• (2) 5 mm trocar.
• Graspers and atraumatic graspers. The patient is under general anesthesia with
• Hook. arms tucked in. Then a 10 mm port, which will
• Scissors. serve as the camera port, is inserted at the left
• Suction. midclavicular line midpoint between the left
• Endostaplers/Laparoscopic linear cutter costal margin level and anterior superior iliac
staplers. spine (ASIS) level. This can be done using an
• Needle holder. optical view trocar or via Hasson’s technique.
• Ultrasonic energy devices (e.g., Harmonic™, Avoid going too lateral to avoid injuring the
Ethicon, Mexico). descending colon. Pneumoperitoneum is created
• Specimen bag. with CO2 pressure at 12 mmHg and flow rate at
Meckel’s Diverticula 105
medium or 20 L/min. A 5 mm port is then sutures in a running single layer fashion. Check
inserted in between the 10 mm port and ASIS for any bleeding. The mesenteric defect is closed
and a 12 mm port, which will serve as the work- with figure of 8 sutures to prevent herniation of
ing port, in between the 10 mm port and costal the intestines. Copious irrigation is done if there
margin. The 5 mm and 12 mm ports can be inter- is spillage of intestinal contents or if dealing with
changed depending on the preference of the sur- a perforated Meckel’s diverticulum.
geon. Avoid putting it too near the costal margin The Meckel’s diverticulum is then placed
and the ASIS as the bones might limit your inside a specimen/collection bag and extracted.
movements. All of this is done under direct Remove the trocars under direct vision to observe
vision to avoid injuring any vessels or intestines. for any port side bleeding. Desufflation is then
A diagnostic laparoscopy is done. done. The fascia at the 10 mm and 12 mm ports
A bowel run from the ileocecal area is done is closed with figure of 8 sutures to minimize the
using atraumatic graspers until the Meckel’s formation of a hernia in the future. Subdermal
diverticulum is located. Dissect free the Meckel’s interrupted skin closure with 4–0, monofilament,
diverticulum if there are any adhesions using a absorbable sutures is done to close the skin
hook or an ultrasonic energy device. incisions.
If a simple diverticulectomy is planned, this
can be done using an endostapler/linear cutter
stapler. The diverticulum is transected at the base. Postoperative Care
Making sure not to compromise the lumen of the
intestine and not to leave behind a stump of the Antibiotics is continued to complete for 7 days
diverticulum. with adequate pain control. Patient is advised to
On the other hand, if segmental resection is to ambulate as soon as possible. Oral intake is
be done, mesenteric openings are made around started once return of bowel functions is observed.
5 cm from the base of the diverticulum proxi- Patient is discharged once vital signs are stable
mally and distally. The mesentery connecting to with complete return of bowel function and able
the diverticulum is then serially ligated and tran- to tolerate oral intake. Patient is then seen after
sected using an ultrasonic energy device. 7–10 days for follow-up.
The Meckel’s diverticulum is then transected
segmentally using linear cutter staplers. The
proximal and distal small intestines are then Complications and Management
aligned in preparation for a side-to-side anasto-
mosis, and a stay suture is placed at the proximal One of the possible complications of resecting a
and distal small intestines to stabilize it. Always Meckel’s diverticulum is anastomosis leakage.
make sure that the intestines are not twisted. If this is suspected immediate repair is war-
Another 5 mm port can be inserted so that another ranted either via laparoscopy or open laparot-
grasper can be used to hold the stay suture and lift omy. Intra-abdominal abscess might also occur,
the intestines to be anastomosed. which can be managed by intravenous antibiot-
A small enterotomy is done at the proximal ics and percutaneous drainage. Wound infection
and distal intestine. Inspect the lumen if there is might also be encountered. This can be treated
any bleeding. After which anastomose the proxi- by antibiotics and drainage. Another possible
mal and distal intestine using the endostaplers/ complication as with other abdominal opera-
linear cutter staplers. The common channel is tions is intestinal obstruction secondary to post-
then closed via intracorporeal suturing with 2–0 operative adhesions.
106 E. L. Sta Clara
References diverticulum in adults. JSLS. 2014;18:e2014.00349.

https://doi.org/10.4293/JSLS.2014.00349.
5. Rho JH, Kim JS, Kim SY, Kim SK, Choi YM, Kim
1. Ajaz AM, Bari SU, et al. Meckel’s diverticulum–
SM, Tchah H, Jeon IS, Son DW, Ryoo E, et al.
revisited. The Saudi Journal of Gastroenterology.
Clinical features of symptomatic meckel’s diverticu-
2010;16(1):3–7.
lum in children: comparison of scintigraphic and non-
2. Palanivelu C, Rangarajan M, Senthilkumar R,
scintigraphic diagnosis. Pediatr Gastroenterol Hepatol
Madankumar MV, Kavalakat AJ. Laparoscopic man-
Nutr. 2013;16:41–8.
agement of symptomatic Meckel’s diverticula: a sim-
6. Sharma RJ, Jain VK. Emergency surgery for Meckel’s
ple tangential stapler excision. JSLS. 2008;12:66–70.
diverticulum. World Journal of Emergency Surgery.
3. Lequet J, Menahem B, Alves A, et al. Meckel’s
2008;3:27.
diverticulum in the adult. Journal of visceral sugery.
2017;152(4):253–9.
4. Hosn MA, Lakis M, Faraj W, Khoury G, Diba
S. Laparoscopic approach to symptomatic meckel
Emergency Groin Hernia Repair
George Pei Cheung Yang
Introduction switch in surgical steps sequence in the manage-

ment of emergency groin hernia situations. In
Laparoscopic groin hernia repair (inguinal, fem- open approach, once the strangulated bowel is
oral, and obturator hernias) has become one of isolated, then time is spent for the bowel to show
the gold standard for elective groin hernia treat- any sign of recovery. If the extent of strangula-
ment since its introduction in 1990 [1]. For tion is unclear, or viability is in doubt, then lapa-
almost 30 years onward, the techniques of laparotomy or bowel resection will be performed. In
roscopic groin hernia repair are divided into two the laparoscopic approach, after diagnostic lapa-
mainstreams, namely the transabdominal pre- roscopy and reduction of the strangulated bowel
peritoneal (TAPP) [2, 3] and totally extraperito- is carried out, instead of purely waiting for the
neal (TEP) [4] approaches. These two surgical recovery of the bowel viability, surgeons will
techniques have withstood the test of time, with proceed to groin hernia repair first, either laparo-
high success and low morbidity rate [5–7]. scopically or open repair. Once the hernia repair
As the techniques become more mature, also is completed, the surgeon then comes back to
deeper understanding of the preperitoneal anat- recheck the viability of the bowel. That in turn
omy, and with more structural surgical training, gives ample time for the strangulated bowel to
naturally surgeons have broadened its applica- recover hence reducing the bowel resection rate.
tions into more complex scenarios. Now it has The clear advantages of laparoscopy in accessing
expanded from elective noncomplicated groin the strangulated content, and the extended time
hernia to complex and emergency groin hernia allowed for the strangulated bowel to recover in
situations [8, 9], similar to laparoscopic chole- a warm intra-peritoneal environment, all of these
cystectomy for acute cholecystitis. are the key factors in reducing the rate of unnec-
Many expert centers have applied laparoscopic essary laparotomy and bowel resection in emer-
approach in the management of acute emergency gency laparoscopic of groin hernia [10–12]. It is
groin hernia situations with a favorable outcome. well known that the moment when laparotomy is
The difference in outcome between laparoscopic decided, that is the major cause for subsequent
and open surgery is believed to be due to the morbidity and mortality.
In this chapter, we will be mainly discussing
the technical aspect of Laparoscopic approach in
G. P. C. Yang (*) the management of acute emergency groin hernia
Hong Kong Hernia Society, Hong Kong, China
situations.
Hong Kong Adventist Hospital, Hong Kong, China
e-mail: george.yang@hkah.org.hk

https://doi.org/10.1007/978-981-19-3755-2_19
108 G. P. C. Yang
Indications There are specific contraindications for par-

ticular steps in the laparoscopic approach for
Any adult patient who is hemodynamically stable emergency groin hernia situations, such that
with acute strangulated or incarcerated groin her- alternative techniques should be considered:
nia can benefit from laparoscopic approach.
Those with previous appendicectomy through 1. In a patient who is on anticoagulant because of
grid iron incision; and those with previous upper cardiovascular or cerebrovascular reasons, lap-
midline laparotomy for upper gastrointestinal or aroscopic hernia repair should probably not be
hepatobiliary surgery can also benefit from lapa- the choice. It is because the area of dissection is
roscopic approach. far greater than open hernia repair. Any bleed-
ing after TAPP or TEP can accumulate into a
substantial amount before the tamponade effect
Contraindications takes place to slow down the bleeding.
However, the rest of the steps including
As with all laparoscopic approaches for emer- diagnostic laparoscopy, laparoscopic-assisted
gency surgical pathologies, there are some com- reduction of strangulated hernia, and bowel
mon contraindications: resection to be performed through smaller
extended sub-umbilical port wounds can be
1. For clinically and hemodynamically unstable carried out to reduce postoperative morbidity
patients, open surgery should be a lifesaving and mortality.
choice. 2. If the operating surgeons or theater assisting
2. In cases where there is markedly distended staffs are not familiar with laparoscopic sur-
abdomen, open surgery should be the choice gery, open approach should be considered;
of approach. The limited space in the perito- 3. If the surgeon has inadequate training on lapa-
neal cavity will substantially increase the dif- roscopic hernia repair, the hernia repair part
ficulty of the surgery, prolong the time of should be performed as open repair;
surgery, and increase the chance of injury to 4. If there is no progress after prolonged period
peritoneal viscera; of time, most likely in the reduction of stran-
3. In patients who have a limited cardiopulmo- gulated hernia, hybrid approach—which
nary reserve, pneumo-peritoneal will run the means making an incision over the strangu-
risk of destabilizing their cardiopulmonary lated mass to openly assist in releasing the
system function; strangulation and reduction of the herniated
4. Those groups of patients which post a higher content should be carried out.
risk of mesh infection and postoperative com-
plications, including those with ascites from
liver cirrhosis and renal failure patients with Preoperative Assessment
peritoneal dialysis. In these conditions, open
tissue repair should be considered. Anesthetic assessment, routine blood test like
5. Those patients who have gone through multi- complete blood count, renal function, clotting
ple laparotomies previously, an open approach profile, ECG, and CXR should be done preopera-
should be the choice of surgery. tively because this is a surgical emergency with
6. If there is a lack of supporting equipment to operation requiring pneumo-peritoneum under
perform laparoscopic approach, then an open general anesthesia.
approach should be the considered; Preoperative CT scan of the abdomen and
7. If the surgeon has inadequate training in lapa- pelvis:
roscopic management of emergency surgical The fundamental disadvantage of laparo-
condition, open surgery should be performed; scopic surgery for any surgical emergency is the
Emergency Groin Hernia Repair 109
limited working space to perform the surgery. 6. Absorbable Tacker (optional).

This limited working space will 7. Cyanoacrylate glue for mesh fixation
(optional).
1. Obscure the visual fields such that sometime 8. Laparoscopic needle holder and sutures
other pathology might be missed; (optional).
2. It also increases the risk of visceral injury dur- 9. Ultrasonic dissector (optional).
ing surgery.
To minimize these disadvantages, a preopera- Patient Position

tive CT scan of the abdomen and pelvis should be
done so that the surgeon can get as much informa- This is similar to routine laparoscopic groin her-
tion as possible on the site of hernia pathology, any nia repair;
concurrent pathology within the abdomen, any
free gas and bowel vascularity on contrast phase • The patient is positioned supine with both
scan, and the extend of bowel dilatation as well. arms tucked by the side and patient strapped
This preoperative CT scan helps to direct the securely as titling of the patient is often
surgeon on where to look for once they enter the required;
peritoneal cavity laparoscopically, and thereby • Foley catheter should be inserted to reduce
reducing the operative time. It also helps to bladder distension and also monitor urine out-
reduce the chance of any unexpected surprise, put intra- and postoperatively for any surgical
such as strangulated urinary bladder herniation emergency;
through direct inguinal hernia, in such case the • The surgeon stands on the opposite side of the
surgeon should be prepared for a hybrid approach pathology;
to reduce the strangulated bladder. • The assistant if available should stand beside
the surgeon near the cephalad part of the
patient;
Operating Theater Setup • The video monitor should be placed at the
patient legs side caudally;
The operative theater setup should be one that is
equipped for laparoscopic surgery including car- The working trocars port should be as follow:
bon dioxide insufflator, laparoscopic imaging
and light source unit, and monitors. • A 10 mm sub-umbilical port for laparoscope;
• (The surgeon has to decide whether TAPP or
TEP will be used before placing the working
Instruments intraperitoneal 5 mm trocars for reduction of
strangulated hernia. It is because if the sur-
1. A 10 mm 30° laparoscope. geon prefers TEP approach, then the perito-
2. A 10 mm and two to four 5 mm laparoscopic neal laparoscopic working ports should be
trocar, should all be Blunt tip ports to avoid placed well away from the TEP working fields
inadvertent injury to the bowel. to avoid a gas leak.)
3. Standard 5 mm a-traumatic laparoscopic • Usually, for peritoneal laparoscopic bowel
bowel grasper. reduction, two 5 mm ports should be placed,
4. Laparoscopic 5 mm Diathermy scissor one on each flank of the patient (Fig. 1).
(optional). • For TEP hernia repair, additional two 5 mm
5. Mesh (either laparoscopic groin hernia mesh working ports should be placed at the lower
or open groin hernia mesh depends on sur- midline position, or as the surgeon’s usual
geon preference). preference.
110 G. P. C. Yang
2. Identify the site of hernia and the strangulated

viscera
(a) The patient should be tilted to aid the
exposure of the pelvis, at least 45 head
down or more. Therefore, preoperatively
the surgeon should make sure the patient
is securely strapped.
3. Laparoscopic reduction of the strangulated
viscera
(a) The reduction of strangulation is proba-
bly the most difficult part and determin-
ing steps in the whole surgery. It is vital to
Fig. 1 Port placement
avoid any injury to the strangulated
bowel. So external compression in the
Surgical Technique correct axis directed by laparoscopy
should be carried out, assisted by gentle
Acute surgical emergency for groin hernia refers pulling from inside using a traumatic
to strangulated groin hernia (inguinal/femoral/ bowel grasper.
obturator) with the involved viscera having a (b) Tips and tricks in reduction of strangu-
variable degree of ischemia. This is a disease lated contents including.
with a wide spectrum of presentation. Fortunately, i. Grasping on and reducing the nones-
in the majority of the cases, the ischemic viscera sential part, including omentum,
are reversible after reduction. Only with the mesentery but need to avoid injuring
extreme spectrum where gangrenous changes the mesenteric vessels;
occur or even more extreme situations when per- ii. Compression of the strangulated con-
foration occurs. tent to reduce edema;
iii. Manual compression externally to
1. Diagnostic laparoscopy via sub-umbilical reduce the strangulated content;
wound iv. In extreme cases where the strangu-
(a) The creation of sub-umbilical wound lated content could not be reduced, a
should take extra care because of the possi- hybrid approach should be employed.
bility of injuring the underlying bowel This means open reduction, with an
loops. Before making the incision on the additional incision over the herniated
fascia, the surgeon should pull the umbili- mass, release of the strangulation ring
cus as far up as possible to lift the umbilicus or adhesion in order to aid the com-
away from the underlying bowel loop. The plete reduction of the strangulated
surgeon should carefully incise the fascia content;
without piercing through the peritoneum. 4. Groin hernia repair
The peritoneum should be punctured using (a) After reduction of the strangulated vis-
blunt grasping forceps. And most impor- cera, the surgeon should now decide on
tantly only use blunt tip trocars. the mode of hernia repair. In most cases
(b) Two additional 5 mm ports are usually of strangulation, it is either the small
required to manipulate the bowel for clear bowel or omentum involvement. As long
assessment. These two 5 mm trocars as there is no perforation, mesh repair for
should be inserted under direct vision and groin hernia should be feasible. The
blunt tip trocars should always be used to surgeon can decide if laparoscopic or

avoid inadvertent injury to the dilated open groin hernia repair should be carried
bowel. out.
(b) Contralateral groin hernia if found should dilated bowel loops in the peritoneal cav-
be repaired at the same time as well. It is ity, it is much safer and also the mesh has
quite often to encounter bilateral femoral less chance to come into contact with the
or obturator hernia. And also concurrent peritoneal fluid and bowel loops thus the-
femoral/obturator hernia can be found in oretically less chance of contamination.
patients with inguinal hernia. These pel- (g) Open groin hernia repair. The surgeon
vic floor hernias should all be repaired in can carry out groin incision and open
the same session. groin hernia repair for inguinal hernia,
(c) For pelvic floor hernia, laparoscopic and open repair for femoral hernia.
repair should be employed; 5. Re-laparoscopy for the reassessment of the
(d) Laparoscopic groin hernia repair—which strangulated viscera viability.
method of repair, namely TAPP or TEP, is (a) During this part of surgery, the strangu-
rather based on the surgeon’s preference lated bowel should be assessed by several
and his surgical training. The surgeon factors:
should use his/her best-trained (b) If there is any pulsation along the mesen-
technique. teric artery supplying the involved seg-
i. For TAPP there is the advantage of ment of the bowel.
using the same laparoscopic ports and (c) If the serosa surface of the involved bowel
operating within the same peritoneal is intact.
space. (d) If there is peristalsis of the involved
ii. For TEP, there are advantages in work- bowel.
ing in a completely different plane so (e) If there is any improvement in the vascu-
as to reduce the chance of bowel larity of the involved bowel (picture
injury, avoid the need for cutting should be taken before and during this
instruments to create the peritoneal time for comparison).
flap, and also have the mesh without 6. Decision if bowel resection is required.
ever touching the peritoneal cavity. (a) If small bowel resection is required, it
(e) TAPP—using the same 5 mm working should be performed through an extended
port, peritoneal flap is created and hernia sub-umbilical port wound. Usually, a
repair is carried out. However, with TAPP 3–4 cm length wound is all that requires
technique the surgeon should take extra to bring out the small bowel for section.
care when the instruments are moving in (b) In an extremely rare situation, if large
and out of the working ports. It is because, bowel resection is required, an expert
with dilated bowel and patient position colorectal laparoscopic surgeon should be
tilted, the instruments can cause direct called in for assistance to perform a lapa-
puncture injury to the bowel loops during roscopic large bowel resection. If none is
insertion through the trocars; therefore, available, then a conversion to an open
iatrogenically cause fecal contamination approach should be carried out.
to the peritoneum. 7. Conclusion of the surgery
(f) TEP—the surgeon enters the preperito- (a) During recheck peritoneal laparoscopy,
neal space through the same sub-umbilical most importantly the surgeon must make
port skin wound, incised on the anterior sure there is no inadvertent injury to the
fascia, enters the retromuscular plane and bowel loops. If occult injury goes un-
then the preperitoneal plane. Additional notice, major morbidity or even mortality
two 5 mm working ports are inserted at will arise postoperatively. The occult
the lower midline. Usual TEP groin her- injury can be caused by instruments going
nia repair is carried out. Since the surgeon in and out of the trocar during surgery
is working at a different plane to the while the patient is titled with bowel
112 G. P. C. Yang
loops sitting right in front of the trocars, Postoperative Care

especially with cutting instruments. This
is why some surgeons prefer TEP rather Because this is a disease with a spectrum of
than TAPP in order to minimize this presentation ranging from (1) omentum stran-
possibility. gulation; (2) strangulation of bowel with differ-
(b) Recheck the strangulated segment of the ent levels of ischemia which recovered after
bowel loop together with its mesenteric reduction; and (3) strangulation with gangre-
vessels. nous bowel required bowel resection. The speed
(c) Recheck if there is any peritoneal defect of recovery directly depends on their disease
which might expose the mesh. status.
For group 1, the patient can effectively resume
oral feeding once they are fully awake after the
Complications and Management surgery, and consider discharge home within the
next 24 h.
The major complication one needs to avoid dur- For group 2, the patient can resume on clear
ing laparoscopic surgery for emergency hernia water to soft diet depending on the level and time
condition is an inadvertent injury to the dilated of bowel ischemia. They can usually be dis-
bowel loop leading to fecal peritoneum. charged within 24–48 h.
That is why the surgeon has to take extra care For group 3, because of bowel resection and
when the laparoscopic instruments go in and out anastomosis, they should be kept nil by mouth for
of the trocars, especially when sharp cutting several days until the anastomosis heal.
instruments and energy device is being used and Antibiotics should be given, intraoperatively
when the patient is tilted to gain additional work- and continue for a course postoperatively to
ing space. lower the risk of wound infection and mesh infec-
It is also important to prevent any occult injury tion rate.
to the bowel which the surgeon might miss dur- During the postoperative recovery period over
ing the operation. This is usually iatrogenic the next 24–48 h, patient abdominal condition
caused by instrumentation. That is why TEP and vital signs should be monitored. This is to
repair is the preferred choice of repair by some detect if there is any occult bowel injury that
surgeons. Since working in a completely differ- might be missed during surgery. So if there is any
ent plane, it minimized the chance of iatrogenic deterioration, or rapid recovery does not occur,
bowel injury. the surgeon should be cautious and investigate
In case there is a bowel injury, the surgeon the causes and subsequent salvage surgery should
must quickly control the injured site and consider be performed as soon as possible if occult bowel
conversion to open surgery. Because the bowel injury is the case. In this respect, TEP approach
loops are usually distended, and therefore leaking after laparoscopic reduction of the strangulated
of fecal fluid might be very extensive once the bowel should be considered.
injury occurs. Plan B should always be in the sur-
geon’s mind to handle a situation like this during
the surgery. References
Mesh infection is not common in emergency
hernia surgery, even in open approach with 1. Ger R, Monroe K, Duvivier R, et al. Management of
indirect inguinal hernias by laparoscopic closure of
Lichtenstein’s repair. the neck of the sac. Am J Surg. 1990;159:370–3.
It depends on the degree of bowel ischemia 2. Arregui ME, Davis CJ, Yucel O, Nagan
and contamination of the operative field. Mesh RF. Laparoscopic mesh repair of inguinal hernia using
should be avoided in the extreme end of the spec- a preperitoneal approach: a preliminary report. Surg
Laparosc Endosc. 1992;2:53–8.
trum where bowel ischemia with perforation is 3. Dion JM, Morin J. Laparoscopic inguinal herniorrha-
encountered. phy. Can J Surg. 1992;35:209–12.
4. Barry McKernan J, Laws HL. Laparoscopic repair of management of strangulated inguino-crural hernias: a
inguinal hernias using a totally extraperitoneal pros- report of nine cases. Hernia. 2008;12:185–8.
thetic approach. Surg Endosc. 1993;7:26–8. 9. Miki Y, Sumimura J, Hasegawa T, et al. A new tech-
5. Memon MA, Cooper NJ, Memon B, Memon MI, niques of laparoscopic obturator hernia repair: report
Abrams KR. Meta-analysis of randomized clinical tri- of a case. Jpn J Surg. 1998;28:652–6.
als comparing open and laparoscopic inguinal hernia 10. Yang GPC, Chan CTY, Lai ECH, Chan OCY, Tang
repair. Br J Surg. 1900;12:1479–92. CN, Li MKW. Laparoscopic versus open repair for
6. Hernia Trialists Collaboration EU. Laparoscopic strangulated groin hernias:188 cases over 4 years.
versus open groin hernia repair: meta-analysis of Asian J Endosc Surg. 2012;5(3):131–7.
randomized trials based on individual patient data. 11. Lavonius MI, Ovaska J. Laparoscopy in the evalu-
Hernia. 2002;6(1):2–10. ation of the incarcerated mass in groin hernia. Surg
7. Neumayer L, Giobbie-Hurder A, Jonasson O, Endosc. 2000;14:488–9.
Fitgibbons R Jr, Dunlop D, Gibbs J, Reda D, 12. Hayama S, Ohtaka K, Takahashi Y. Laparosopic reduc-
Henderson W. Open mesh versus laparoscopic tion and repair for incarcerated obturator hernia: com-
mesh repair of inguinal hernia. N Engl J Med. parison with open surgery. Hernia. 2015;19:809–14.
2004;350:1819–27.
8. Legnani GL, Rasini M, Pastori S, Sarli D. Laparoscopic
trans-peritoneal hernioplasty (TAPP) for the acute
Laparoscopic Subtotal
Cholecystectomy
Michael M. Lawenko
Introduction Contraindications
Severely inflamed gallbladders due to acute or • Severe adhesions make it hard to access the
chronic infections are challenging to operate on gallbladder.
laparoscopically. This is due to the difficulty of • Hemodynamic instability (systolic
adequate ductal identification using the critical pressure < 90 mmHg).
view of safety (CVS), which increases the risk of • Bleeding and clotting problems.
bile duct injury. The safer method would be to
avoid dissection in the hepatocystic triangle and
perform a subtotal laparoscopic cholecystectomy. Instruments
The two types of subtotal cholecystectomy, based
on the remaining remnant gallbladder would be • Laparoscopic hook.
fenestrating (no remnant) and reconstituting • Laparoscopic blunt graspers.
(remnant present) [1]. • Laparoscopic toothed graspers.
• Maryland forceps.
• Laparoscopic needle holders.
Indications [2] • Suction-Irrigation cannula.
• Advanced bipolar forceps (if available).
• Severe cholecystitis.
• Cholelithiasis in liver cirrhosis and portal
hypertension. Conduct of the Operation
• Empyema or perforated gallbladder.
A 10 mm umbilical incision for a 10 mm Hasson
Trocar. Three 5 mm incisions at the right subcos-
tal area for 5 mm working trocars. Pressure is set
initially at 8 mmHg with a flow rate of low flow
(5 L/min). Once an ideal pneumoperitoneum is
established, pressure is increased to 12 mmHg
and high flow is established (20 L/min). The
patient is set wherein the head is elevated (reverse
M. M. Lawenko (*)
De La Salle Medical and Health Sciences Institute, Trendelenburg position) and the right side of the
Dasmarinas City, Philippines patient is also elevated just enough to let the bow-
e-mail: mmlawenko@dlshsi.edu.ph els fall for exposure of the gallbladder.
https://doi.org/10.1007/978-981-19-3755-2_20
116 M. M. Lawenko
suction cannula
enlarged cystic duct

D perforated fundus
Rouviere’s fissure CBD

D D
Fig. 2 Decompression of a distended gallbladder

Fig. 1 Cystic duct is greatly enlarged making it unsafe to
continue dissecting into the cystohepatic triangle nula tip. Decompression of the GB is continued
by suctioning the liquid contents present in the
A limited diagnostic laparoscopy is con- GB [3] (Fig. 2).
ducted by sweeping the scope around the abdo- The bowel grasper is replaced with a toothed
men to check for concomitant abdominal grasper, situated inside the newly created puncture
pathologies, active bleeding at port site inser- in the fundus to grasp the GB and push it upwards
tions, and/or bowel injuries that might have with just enough space to carry out dissection
occurred during trocar insertions. The area of the around the GB. Dissection to remove the anterior
gallbladder (GB) is assessed for accessibility. In wall of the GB is started at the fundus and carried
the presence of dense and hard omental adhe- down either medially or laterally towards the neck
sions or significant bowel adhesions to the GB, a of the GB. A monopolar hook can be used, being
decision to convert to an open procedure is exe- mindful to address small arterial bleeding with
cuted due to difficulty to access. If the GB is bipolar forceps. An alternative is to carry out dis-
readily visualized, dissection proceeds to isolate section with advanced bipolar forceps to minimize
the cytic duct and artery. Additional maneuvers bleeding, as this has both cutting and vessel sealing
like the fundus down approach can be done at capability (Fig. 3). The posterior wall of the GB is
this point. If the cystohepatic triangle is fused left attached to the liver with the mucosa exposed.
with the cystic artery and/or the cystic duct can- Monopolar energy is applied to the exposed
not be safely dissected, a decision will be made mucosa so as to limit the production of mucin.
to abort dissection into the cystohepatic triangle During dissection of the GB, a specimen bag
and initiate a laparoscopic subtotal cholecystec- is placed inside beside the GB so that the stones
tomy, so as to avoid a bile duct injury (Fig. 1). extracted can be safely set aside by placement in
a specimen bag. Smaller stones can be suctioned
off. This prevents stones from being scattered
Fenestrating Subtotal around the abdomen, which can be challenging
Cholecystectomy for multiple small stones. The removed anterior
wall of the GB can also be placed inside the spec-
Decompression of the GB is started with an open imen bag at this point.
laparoscopic bowel grasper, on the lateral most It must be noted that there must be no more
trocar, which is used to push the GB cephalad. A stones inside the GB stump and bile flow is visu-
suction cannula on the surgeon’s left hand is situ- alized in the orifice of the cystic duct. This is the
ated at the fundus while a monopolar hook is on time that intracorporeal suturing of the orifice of
the surgeon’s right hand to puncture the fundus of the cystic duct with a 2–0, braided, nonabsorb-
the GB just large enough to fit the suction can- able suture via purse string closure is done.
Laparoscopic Subtotal Cholecystectomy 117
postrior part of GB
attached to liver
transection of the
neck of the GB
anterior part
of GB being
dissected out
Fig. 4 Reconstituting subtotal cholecystectomy by tran-

Fig. 3 Fenestrating subtotal cholecystectomy wherein secting the neck of the GB
part of the GB is attached to the liver
Using the suction irrigation cannula, copious GB has a thickened wall, a 5 mm advanced bipo-
lavage with plain saline solution for irrigation is lar forceps can be used throughout the dissection,
done at the operative field, around the inferior being cautious when reaching the neck of the GB
and lateral borders of the liver to clean out small as the common hepatic duct can be adherent to
stones and spilled bile. A closed suction drain is the inflamed neck of the GB. It is of importance
placed at the inferior margin of the liver close to that dissection has proceeded to a point that the
the GB stump with the proximal end exiting the GB is freed from the liver up to the area of the
most lateral 5 mm trocar. A last look to assess the neck. This is the point wherein transection of the
integrity of the anatomy of the extrahepatic bili- neck of the GB is done, either with a monopolar
ary tree is done by taking note that there are no hook or an advanced bipolar forceps (Fig. 4).
signs of bleeding and bile leak. The remaining Proper hemostasis must be done once arterioles
working trocars are removed under direct vision are transected. The stones are removed and
making sure that there are no signs of active port placed into a specimen bag, together with the
site bleeding. Dessuflation is done and the speci- transected part of the GB. Visualization of the
men bag is extracted through the umbilical inci- orifice of the cystic duct is done with minimal
sion. Proper closure of incision sites is done. probing with the Maryland forceps just to make
sure that there are no stones lodged inside the
cystic duct and that flow of bile is noted. Burning
Reconstituting Subtotal of the stump mucosa is commenced with a mono-
Cholecystectomy polar hook. Intracorporeal suturing with a 2–0
absorbable barbed suture is needed to close off
With the same indications for doing a subtotal the stump (Fig. 5).
cholecystectomy, since it is very difficult to Copious suction and irrigation are done
approach the hepatocystic triangle, the fundus of around the operative field so as to clean away
the GB is perforated with the same technique dis- small stones and bile. A closed suction drain is
cussed above. A dome-down technique is com- placed lateral and inferior to the gallbladder
menced wherein the GB is separated from the stump with the distal end coming out of the lat-
liver by a monopolar hook from the posterior part eral trocar insertion site. A last look to assess the
of the fundus up to the posterior part of the neck integrity of the anatomy of the extrahepatic bili-
of the GB [4] (Fig. 2). Bleeding is common in ary tree is done by taking note that there are no
this step, wherein control can be done with signs of bleeding and bile leak. Remaining work-
advanced bipolar forceps from time to time. If the ing trocars are removed under direct vision mak-
118 M. M. Lawenko
self-locking barbed
suture
intracorporeal
closure suturing of
GB Stump
Fig. 5 Closure of the GB stump with a barbed suture
ing sure that there are no signs of active port site 2. Elshaer M, Gravante G, Thomas K, et al. Subtotal
cholecystectomy for “difficult gallbladders” sys-
bleeding. Dessuflation is done and the specimen tematic review and meta-analysis. JAMA Surg.
bag is extracted through the umbilical incision. 2015;150(2):159–68.
Proper closure of incision sites is done. 3. Shin M, Choi N, Yoo Y, et al. Clinical outcomes of sub-
total cholecystectomy performed for difficult chole-
cystectomy. Ann Surg Treat Res. 2016;91(5):226–32.
4. Purzner RH, Ho KB, Al-Sukhni E, et al. Safe laparo-
References scopic subtotal cholecystectomy in the face of severe
inflammation in the cystohepatic triangle: a retrospec-
1. Strasberg SM, Pucci MJ, Brunt ML, et al. Subtotal tive review and proposed management strategy for the
cholecystectomy-“Fenestrating” vs “reconstituting” difficult gallbladder. J Can Chir. 2019;62(6):402–41.
subtypes and the prevention of bile duct injury: defi-
nition of the optimal procedure in difficult operative
conditions. J Am Coll Surg. 2016;222(1):89–6.
Adhesiolysis for Bowel
Obstruction
Raquel Maia
Introduction roscopic group, but also the mortality at 30 days

was higher in the open group (4.7 vs. 1.3%) [3].
Abdominal surgery is the major cause of perito-
neal adhesion formation. Although being part of
the body’s healing process, it is estimated that Indications
intra-abdominal adhesions are developed in
90–95% of patients. Other causes of intra- Patients with small bowel obstruction (SBO)
abdominal adhesions include pelvic inflamma- should be carefully selected for laparoscopic
tory disease, spontaneous bacterial peritonitis, adhesiolysis. Moreover, all attempts must be
and complicated diverticulitis [1]. taken to treat stable patients conservatively. Some
Consequences of adhesions may range from bowel obstructions can be successfully resolved
chronic pain, infertility to partial or total intestine with no oral intake, nasogastric tube for decom-
obstruction, bowel necrosis, and death if not pression, intravenous fluid resuscitation, bladder
addressed adequately. catheter to closely follow the urine output, and
Laparoscopy for adhesiolysis has some advan- antibiotics if fever or leukocytosis is present. The
tages when compared to the open approach: (1) ultimate goal is to avoid a scenario where small
earlier recovery of gastrointestinal function; (2) bowel necrosis is installed. Physical examina-
decrease in incidences of ventral hernias; and (3) tion, radiologic study of the abdomen with water-
shorter length of hospitalization. However, Yao soluble contrast, and tomography are valuable
et al., in a study with 156 patients submitted to tools to follow up on the evolution of SBO cases.
either open or laparoscopic approach for adhe- If it all fails in 24–48 h, the surgical approach
siolysis concluded that the incidence of reopera- must be considered without further delay.
tions for obstruction was higher in the laparoscopic Patients with (1) partial obstruction; (2) SBO
group (7.7 vs. 0%) [2]. that fails with conservative management in a sta-
In another study, Kelly et al., evaluate more ble patient; (3) Chronic pain and (4) recurrent
than 9.000 patients from a database, comparing obstruction are the best indications for laparo-
the 30 days outcome in both laparoscopic and scopic adhesiolysis [4].
open groups. As expected, the rate of major inci-
sion complications was less frequent in the lapa-
Contraindications
R. Maia (*)
Brazilian College of Gastric Surgeons, • Diffuse peritonitis.
Sao Paolo, Brazil • Vascular compromise or perforation.
https://doi.org/10.1007/978-981-19-3755-2_21
120 R. Maia
• Hemodynamic instability. OT Setup

• Patient who is unable to tolerate pneumoperi-
toneum or refuse the procedure. The patient should be placed in supine position
• “Frozen” abdomen due to carcinomatosis or with arms tucked at the sides and both arms and
matted adhesions. legs are safely secured in a flat position. Keep in
mind that a steep Trendelenburg or reverse
Trendelenburg position might be needed during
Preoperative Assessment the procedure.
and Patient Preparation Two monitors should be placed either on each
side of the patient’s head or one in the head and
• Abdominal radiography especially if a com- the other one near the opposite hip, depending on
plete obstruction is suspected (Fig. 1). the surgeon’s discretion.
• Tomography (CT) to identify major complica- The surgeon must be placed on the opposite
tions such as necrosis, presence of pneumato- side of the first trocar placement site [5].
sis of the bowel, transition point of obstruction, The instruments needed must include:
and cause of SBO.
• Fluid and electrolytes replacement and acido- • 3–5 trocars;
sis correction. • Angled scopes.
• Preoperative antibiotics. • Laparoscopic atraumatic graspers.
• Nasogastric tube in low continuous suction. • Blunt-tipped scissors.
• DVT prophylaxis. • Handport device in case of a hybrid approach
• Bladder catheterization. for bowel suturing or resection (optional).
• General anesthesia. • Laparoscopic staple if bowel anastomosis is
• Laparotomy tray available. needed.
• Bipolar or harmonic scalpel. • Suction-irrigators for aqua dissection (optional).
Surgical Technique
• The first trocar should be placed in virgin ter-

ritory, at least 5 cm away from any previous
scar, and using Hasson’s technique. Both
RUQ and LUQ are good options for entering
the abdomen.
• The second trocar is placed in an area away
from adhesions. Keep in mind the triangula-
tion when positioning the trocars.
• Start the procedure by releasing the adhesions
to the anterior abdominal wall that looks filmy
and avascular.
• Use gravity, CO2 pneumoperitoneum, and
work above the adhesions to delineate a plane.
• Scissor is the best tool to release the adhe-
sions. Insert a blunt—tip scissor in an avascu-
lar plane between the peritoneum or omentum
Fig. 1 Rx of small bowel obstruction (personal file) and the adhesion, open and withdraw it
Adhesiolysis for Bowel Obstruction 121
opened. Repeat this step as many times as • At any time, do not hesitate to convert if adhe-
needed to clear the adhesions. Use gentle sions are too dense, if pneumoperitoneum
atraumatic traction to expose the plane. cannot be achieved due to bowel distention,
• Always start from a plane where is easier to and especially if bowel resection is needed.
identify the anatomy, rather than an unknown • If the integrity of an anastomosis is uncertain,
territory. a diverting ostomy should be considered.
• When facing a thick, dense, and vascular • Be patient!
adhesion, use electrosurgical energy to cauter-
ize and then divide the plane. A harmonic
scalpel is a better option, but consider that the Postoperative Care
jaws are hot when in use. Avoid thermal injury.
• Any incidental enterotomies must be repaired • Analgesia with non-opioid medication.
as soon as they are detected to avoid cavity • A liquid diet can be initiated on the first day.
contamination. • The patient can be discharged once bowel
• Any nonviable ischemic bowel segment movements have returned and flatus are
should be resected and an end-to-end or side- present.
to-
side anastomosis is performed. Surgical
staples can be used and in more complex cases
a hybrid approach, e.g., hand-assisted laparos-
copy is of use. References
• Move into the pelvis to release adhesion with
the omentum. Keep in view both ureters’ tra- 1. Eillis H. The clinical significance of adhesions:
focus on intestinal obstruction. Eur J Surg Suppl.
jectories to avoid damage. 1997;(577):5–9.
• When the obstruction stopping point is freed 2. Yao S, Tanaka E, Matsui Y, Ikeda A, Murakami T,
from adhesions, run the bowel with gentle Okumoto T, et al. Does laparoscopic adhesiolysis
atraumatic graspers to search for any unno- decrease the risk of recurrent symptoms in small
bowel obstruction? A propensity score-matched anal-
ticed bowel injury. ysis. Surg Endosc [internet]. 2017;31(12):5348–55.
• Carefully review the hemostasis and wash the https://doi.org/10.1007/s00464-017-5615-9.
cavity copiously. 3. Kelly KN, Iannuzzi JC, Rickles AS, Garimella V,
Monson JRFF. Laparotomy for small-bowel obstruc-
tion: first choice or last resort for adhesiolysis? A
laparoscopic approach for small-bowel obstruc-

Tips tion reduces 30-day complications. Surg Endosc.
2014;(1):65–73.
• Start from a clear anatomical site, then move 4. Di Saverio S, Birindelli A, Ten BR, Davies JR,
Mandrioli M, Sallinen V. Laparoscopic adhesioly-
to the more complex areas of adhesions. sis: not for all patients, not for all surgeons, not in all
• Avoid thermal injuries. Late thermal bowel centres. Updates Surg [Internet]. 2018;70(4):557–61.
injury might not be noted until hours or days https://pubmed.ncbi.nlm.nih.gov/29767333
after the surgery. Scissors are the best tool. 5. Villanueva MSS, Roberts KEM. Laparoscopic
Adhesiolysis [Internet]. Medscape. 2019 [cited
• All mesenteric defects should be closed. 2020 Sep 10]. https://emedicine.medscape.com/
• Establish a realistic timeline for the laparo- article/1829759-overview#a2
scopic procedure. If not successful DO NOT
hesitate to convert.
122 R. Maia
Emergency Laparoscopic Small
Bowel Resection
Abdul Gafoor Mubarak
The small bowel forms the majority of “real • Poor blood supply to bowel ends (i.e.,
estate” particularly in the lower abdomen and radiation-injured bowel).
remains to this day one of the most formidable • Unclear bowel viability after a revasculariza-
challenges that a laparoscopic surgeon faces tion procedure.
when he is performing surgery [1]. The common –– Both ends of the small bowel may be
conditions that will require the laparoscopist brought up to skin level as temporary osto-
attention includes. mies if the distal small bowel is involved.
A proximal small bowel ostomy will cre-
1. Blockages either due to adhesions or are ate a high-output fistula that is difficult to
congenital. manage.
2. Bleeding, infection, and ulcers due to disease –– Alternatively, both ends can be stapled
process, i.e., Chron’s disease. closed and a plan made for a second-look
3. Cancer and carcinoids. laparotomy in 24–48 h.
4. Small bowel injury. –– In extreme situations (e.g., acute mesen-
5. Meckel’s Diverticulum. teric ischemia with gangrene extending
6. Precancerous polyps. from the ligament of Treitz to mid colon),
7. Non-cancerous benign tumors. the likelihood of survival is very small.
This is an absolute contraindication to
Inadvertently the most common reason for a attempted resection and anastomosis [3].
small bowel resection would be adhesions [2]. • Inadequate tumor margins.
For simplification purposes, this part will focus –– If a tumor is unresectable, and small bowel
on acquired and not congenital issues which need obstruction is likely to occur, a side-to-side
small bowel resections. anastomosis in the uninvolved bowel prox-
Almost all small bowel resections can be done imal and distal to the obstruction may be
by laparoscopy [1]. If the patient is fit for general performed as a bypass procedure, leaving
anesthesia, they should be fit for a laparoscopic the tumor in situ.
resection option as well. Absolute contraindica-
tion for resection would include
A. G. Mubarak (*)
Island Hospital, Penang, Malaysia

https://doi.org/10.1007/978-981-19-3755-2_22
124 A. G. Mubarak
Relative Contraindications Would between the patient’s legs in either a Trendelenburg

Include or reverse Trendelenburg position (Fig. 1).
It is my contention that if the pathology is
• Peritoneal sepsis. located in the upper small bowel, i.e., the duode-
• Hemodynamically precarious patient. num or the jejunum it would be better to position
• Extensive Crohn’s disease. the patient in a head-down position with the oper-
–– Stricturoplasty should be considered to ator standing between the patient’s legs. However,
minimize the need for extensive resection if the pathology is located in the lower small
and the risk of short gut syndrome; 90 cm bowel, i.e., a Meckel’s diverticulum, the operator
is the approximate shortest length of small should be standing on either side of the patient
bowel that might still support a viable oral with a slight tilt up on the opposite side (Fig. 2).
nutrition program. The patient should be catheterized if the oper-
ation is expected to take some time, i.e., more
The limiting factor is however the operator. than 90 min and there should be considerations
The resection requires an experienced surgeon for DVT prophylaxis according to local norms
whereby some suggest the experience should be and practices. Prophylactic and empirical antibi-
at least someone who is able to perform intracor- otics are also as per local norms and practices.
poreal knotting and suturing comfortably. The Other imaging modalities that can be used to aid
other requirement is the knowledge of patient ori- are as follows:
entation and usage of the operating table includ-
ing the functions of rotations and various • Small bowel follow-through and small bowel
positions. The small bowel is a precarious organ enteroclysis.
that flops around and good control over the • As indicated for bleeding:
mobility of the organ is essential. –– Esophagogastroduodenoscopy, push enter-
Preoperative assessment is a vital step in per- oscopy, or double balloon enteroscopy.
forming small bowel resections [3]. The availabil- –– Capsule endoscopy.
ity of information regarding the location of –– Nuclear scan.
pathology, nature of pathology, and the extent of –– Angiography.
contamination would affect the positioning of the
patient and also placement of trocars. A contrast The three positioning for port placement for
CT scan would be able to show the nature of the patients for small bowel surgery is illustrated in
pathology and also avail information regarding the diagram below (Fig. 3). The placement of ports
contamination if present. This would then be trans- and selection of port placement should be dictated
lated into planning the operation itself. In laparo- by the pathology itself. As mentioned before a CT
scopic small bowel resection, the consideration scan is essential in this regard. The aim is to not
should be if the operator is required to stand in only triangulate the pathology and working space
Fig. 1 Split leg, trendelenburg, and reverse trendelenburg position

Emergency Laparoscopic Small Bowel Resection 125
!st Assistant
2nd Assistant
Surgeon
Fig. 2 Surgeon standing in between legs or on either side of the patient
adhesiolysis is undertaken, the working port can

be enlarged to accommodate the stapler device and
aid in resection and closure.
Surgical Technique and Synthesis
Small bowel resections laparoscopically are always

a balance of finesse and precision [2]. The operator
has to determine the viability of the segment that
remains and how much of the small bowel is actu-
ally going to be resected. The consideration is fur-
ther confounded by the general condition of the
patient, i.e., is the patient septic or bleeding due to
an injury. Once the affected segment is identified,
the surgeon has to perform a detachment procedure
whereby the small bowel is denuded of the blood
Fig. 3 Triangulate pathology during port placement supply. Often an energy device is used for this pur-
pose and the author’s preference is the Ligature
ergonomically but also to ensure that adequate device from Medtronic or the Harmonic Ace by
room is available for not only resection but also to Johnson and Johnson. The addition of separating
accommodate stapler devices and aid in closure the function of sealing and cutting allows more
using intracorporeal sutures. The likely positions control when performing this step. Often however
for port placement are illustrated below. The most the operator can get carried away by the ease of the
general consideration would be for adhesions. The instrument and fail to dissect clear and large vessels
pathology does not allow very much planning but before sealing them and this will lead to obscurity
in general I prefer to place a supraumbilical port of vision and unexpected bleeding.
by an open technique followed by diagnostic lapa- Once the segment of the bowel is denuded
roscopy before inserting the other ports. Once the from the blood supply the resection is under-
126 A. G. Mubarak
taken. It is often done with staplers and the height • Systemic complications of major surgery,
required depends on the thickness of the tissue including pneumonia, venous thromboembo-
however in general a stapler device using a height lism, and cardiovascular events.
of 2.6–3.6 mm is sufficient for the job. It is essen- –– Small bowel obstruction, stricture, and the
tial for the operator to place the segment of resec- need for further surgery are also potential
tion away from the trocar site for this step to aid risks of small bowel resection.
in resection and then anastomoses. Another –– Patients with extensive intra-abdominal
important tip is to use an anchoring stitch to keep sepsis or who are in a malnourished state
the two bowel segments together before stapling are at increased risk for anastomotic leak
for the anastomoses. In general, we can use three and enteric fistula.
staples, i.e., two for the resection ends and one
for the anastomosis or anastomose first and then In summary, small bowel resection is a deli-
resect which will usually always end with three cate and precise procedure that can be undertaken
staples as well. The former technique requires safely by laparoscopy.
closure of the enterotomy created by the stapler
insertion and the latter does not.
The closure of the omental defect after per- References
forming small bowel resection is debatable how-
ever it is the author’s opinion that all defects 1. Gerson LB, Fidler JL, Cave DR, et al. ACG clinical
guideline: diagnosis and management of small bowel
should be closed and the closure of this defect is bleeding. Am J Gastroenterol. 2015;110:1265–87.
relatively easy to perform. Drains are not rou- https://doi.org/10.1038/ajg.2015.246.
tinely recommended. 2. Pennazio M, Spada C, Eliakim R, et al. Small-bowel
capsule endoscopy and device-assisted enteroscopy
for diagnosis and treatment of small-bowel disor-
ders: European Society of Gastrointestinal Endoscopy
Postoperative Management (ESGE) clinical guideline. Endoscopy. 2015;47:352–
and Complication 76. https://doi.org/10.1055/s-0034-1391855.
3. Schottenfeld D, Beebe-Dimmer JL, Vigneau FD. The
epidemiology and pathogenesis of neoplasia in the
Post surgery the patient can be started on clear small intestine. Ann Epidemiol. 2009;19:58–69.
fluids almost immediately in ward and following https://doi.org/10.1016/j.annepidem.2008.10.004.
bowel movement, up-scaled to a nourishing and 4. Cloyd JM, George E, Visser BC. Duodenal adeno-
normal diet. There is a lot of evidence to support carcinoma: advances in diagnosis and surgical man-
agement. World J Gastrointest Surg. 2016;8:212–21.
the fact that bowel movements are faster after https://doi.org/10.4240/wjgs.v8.i3.212.
laparoscopic bowel resections as opposed to 5. Achille A, Baron A, Zamboni G, et al. Molecular
open surgery however the overall postoperative pathogenesis of sporadic duodenal cancer. Br J
stay may not be affected. There is no need for the Cancer. 1998;77:760–5.
6. Markogiannakis H, Theodorou D, Toutouzas KG,
continuation of antibiotics unless there has been et al. Adenocarcinoma of the third and fourth por-
evidence of contamination or infection during the tion of the duodenum: a case report and review
surgery and patients are encouraged to ambulate of the literature. Cases J. 2008;1:98. https://doi.
and mobilize as soon as possible. org/10.1186/1757-1626-1-98.
7. Edge SB, Byrd DR, Compton CC. American
joint committee on cancerstaging manual. 7th ed.
New York: Springer; 2010. p. 127.
Common Complications Include
• Surgical site infection (either deep or

superficial).
• Bleeding.
Emergency Laparoscopic Small Bowel Resection 127
Laparoscopic Hartmann’s
Procedure
Yen-Chen Shao, Ming-Yin Shen,

Introduction 50% [3, 4]. The morbidity rate of Hartmann

reversal is up to 55%, and the mortality rate is
Hartmann’s procedure, Hartmann’s resection, or ranging from 0 to 14% [5–7]. A study showed
Hartmann’s operation is the surgical resection reversal of Hartmann between 3 and 9 months
consisting of sigmoidectomy without intestinal associated with increased risk of postoperative
restoration. It contains an end-colostomy and clo- complications [8]. The mean interval from
sure of a rectal stump. It was first described by Hartmann procedure to its reversal is ranging
Henri Albert Hartmann (1860–1952) for resec- from 7.5 to 9.1 months [3, 5]. We usually delay
tion of rectal or sigmoid cancer [1]. Nowadays, the reversal of Hartmann’s operation at least
Hartmann procedure is usually used in treating 6 months later in our daily practice. Hartmann’s
malignant obstruction of left-sided colon or in procedure and/or reversal of Hartmann’s proce-
emergent conditions, such as sigmoid colon per- dure could be conventional or laparoscopic.
foration [2], mostly because of diverticulum dis- Laparoscopic reversal of Hartmann’s procedure
ease. The advantage of Hartmann’s procedure is is associated with less complications compared
reduction in morbidity and mortality in emergent to the conventional method, especially in wound
settings because it avoids the possibility of com- infection, anastomotic leakage, and cardiopul-
plications from a colorectal anastomosis. For monary complications [3].
patients with unstable hemodynamic status, or
multiple comorbidity or inflammatory condition
of the intestinal tissue, which would make per- Indications
forming a colorectal anastomosis difficult or have
a higher risk of anastomotic leakage, this proce- This procedure is used for left-sided colonic dis-
dure is simple and fast, and meanwhile preserve ease, usually in emergent situations, either preop-
the chance of restoration of intestine continuity eratively or peri-operatively noted. Generally
after patients’ general condition got improve- speaking, when a patient is mandated to a sig-
ment. However, the Hartmann reversal rate is moidectomy, who also has unstable vital signs
variable in different studies, ranging from 0 to (shock status) or multiple comorbidities (ASA IV
patients), which increase the risks of postopera-
tive complications, especially in anastomotic
Y.-C. Shao · M.-Y. Shen · W. T.-L. Chen (*)
Division of Colorectal Surgery, Department of condition, Hartmann’s procedure is an alternative
Surgery, China Medical University Hsinchu Hospital, method. Besides, when the intestine tissue condi-
Zhubei City, Hsinchu County, Taiwan tion is not healthy, such as distention and edema-
e-mail: wtchen@mail.cmuh.org.tw tous change resulting from obstruction, ischemic
https://doi.org/10.1007/978-981-19-3755-2_23
130 Y.-C. Shao et al.
change, and inflammatory fibrosis, or any anterior resection or sigmoidectomy with anasto-
condition would make a colorectal anastomosis mosis, the possibility of stoma creation (either
difficult to perform, Hartmann’s procedure pro- end stoma or loop stoma) should be informed. In
vides a damage control method and avoid any fact, we suggest informing the possibility of
complications followed by an anastomosis. stoma creation in all colonic procedures before
These indications include [9]. doing a surgery, not only for left-sided colonic
lesion. According to many retrospective studies,
1. Colorectal cancer obstruction, only half of the patients could receive a reversal
2. Perforated diverticulitis with peritonitis, of Hartmann’s procedure in the seeing future
3. Ischemic colitis. therefore possible permanent stoma placement
4. Sigmoid volvulus. should be explained.
5. Anastomotic complications, such as leakage
or stricture. Preoperative Testing
6. Abdomen trauma. Before surgery, one should receive preoperative
studies to evaluate the surgical plan and potential
Other less common indications life-threatening condition.
1. Severe low anterior syndrome, mostly when a Laboratory Studies

patient received an ultra-low anterior resec- Complete blood counts and differential count
tion complicated with a poor rectal reservoir (CBC/DC), renal function tests (serum BUN and
function. creatinine), electrolytes (Serum sodium and
2. Surgery in patients with preexisting anal potassium), liver function tests (serum AST and
incontinence. ALT, direct/total bilirubin), pre-transfusion study
(ABO and Rh typing), prothrombin time and
activated partial thromboplastin time (PT and
Contraindications aPTT), are routinely checked preoperatively in
patients who will receive major surgery in our
Patient with unstable hemodynamic status who institute.
could not tolerate general anesthesia is contrain-
dicated. Patient who could not tolerate prolonged hest X-Ray (CxR)
C
pneumoperitoneum is contraindicated for laparo- CxR is routinely checked in our institute, it pro-
scopic Hartmann’s procedure. In an oncological vides information on some major comorbidities,
setting, any condition that would compromise the such as pleural effusion, cardiomegaly, or pulmo-
result is a relative contraindication, such as low nary tuberculosis (especially in South-East Asia).
rectal cancer invading the pelvic floor, in such It is not the gold standard for the diagnosis of
situation, abdominal-perineal combined resec- lung metastasis in colorectal cancer.
tion should be performed.
Electrocardiogram (ECG)
Electrocardiograms are noninvasive, quick, and
Preoperative Assessment effective in detecting potential heart disease. It is
routinely checked in major surgery in our
Preoperative Preparation hospital.
First, an informed consent should be obtained. Abdominal Computed

The indication and risks should be explained to Tomography (CT)
the patient. Most of Hartmann’s procedure is per- Abdominal CT scan with intravenous contrast is
formed under emergent condition, and these useful to assess the disease severity in diverticuli-
patients were initially scheduled to receive an tis disease or tumor obstruction/perforation. In
Laparoscopic Hartmann’s Procedure 131
perforated diverticulitis disease, it provides

operator
information to evaluate whether the surgery

would be a sigmoidectomy with/without divert-
ing stoma, or Hartmann’s procedure. In a patient Camera man
who has malignant obstruction or perforation, it
provides not only the surgical choices but also the
possibility of combined resection of adjuvant
organ which invaded by the tumor. Oral or rectal
contrast is usually not recommended in emergent
condition.
agnetic Resonance Imaging (MRI)

M
Pelvic MRI is now widely accepted as the gold
standard for rectal malignancy; however, it is
usually not available in patients under emergent
condition.
Patient’s left side
OT Setup
Patient’s Position Fig. 2 Operator and camera man
It is better to put the patient in a modified

Trendelenburg lithotomy position (Fig. 1) than in operator (Fig. 2). If there is an assistant, he or she
a supine position. However, in many cases, should be positioned on the patient’s left side.
colorectal surgeons are consulted in the operation
theater by general surgeons for patients with
colonic disease, and these patients are receiving Instrumentations
the surgery under the indication of hollow organ
perforation initially. In such cases, these patients • Trocars:
are usually put in the supine position. • 12 mm trocars ×2: One for camera, another as
The operator should be positioned to patient’s working port
left and the cameraman positioned next to the • 5 mm trocars ×2–4.
• Laparoscopic instruments:
–– Bowel grasping forceps ×2–3.
–– Metzenbaum scissor ×1.
Trendelenburg lithotomy position –– Hook electrode or spoon electrode ×1.
–– Right angle dissection forceps ×1.
–– Energy devises ×1 (alternative: bipolar
forceps).
–– Suction and irrigation system.
Surgical technique
1. Under general anesthesia, the patient should

be put in modified Trendlenburg lithotomy
Fig. 1 Trendelenburg lithotomy position position.
2. A 12 mm camera trocar is inserted near

umbilicus. A 12 mm trocar should be inserted
via right lower quadrant of abdomen; another
5 mm trocar should be inserted via right
abdomen, 8–10 cm away from the 12 mm
trocar (Fig. 3a). You can insert an additional
5 mm trocar via left lower quadrant of abdo-
men for assistant (Fig. 3b).
3. Identified the lesion in diseased sigmoid
colon or rectum, if there is a perforated hole, 5mm
do damage control first. Close the perforated
12mm
hole with sutures and irrigate the peritoneal 5mm
cavity copiously with warm saline. 12mm
4. Gently separate the inflamed tissue surround-
ing the lesion. Use hand instruments to grab
a piece of wet gauze and wipe out the adhe-
sive tissue. Avoid direct dissection between
severely inflamed tissue unless there is a
clear surgical plane. Fig. 3b Port placements
5. Use electrode to free the sigmoid colon from
its peritoneal attachment along the line of
Toldt proximally from the descending colon
and distally to the pelvic inlet (Fig. 4).
6. If the lesion is malignant, such as tumor
obstruction or tumor perforation, adequate
Fig. 4 Dissection along the white line of Toldt
lymph nodes sampling is recommended.

Ligate inferior mesentery artery at its root
just above abdominal aorta (Fig. 5). Perform
complete mesocolon excision as standard
colon cancer surgery. If the lesion is benign,
such as diverticulitis perforation, stercoral
ulcer perforation, or other nonmalignant dis-
eases, dissect mesocolon at the level of mar-
ginal vessels to preserve a better blood
supply to colon is feasible.
7. Select the transection point proximally and
distally. If inferior mesentery artery was
ligated at its root, bowel transection point at
Fig. 3a Trocar insertion upper rectum would be better. Use endocut-
the incision. Reestablish pneumoperitoneum,

check hemostasis, and place a drainage tube
if indicated.
10. Close the trocar wounds layer by layer.
Mature the end-colostomy.
Complications and Management
Wound Infection
Fig. 5 Ligate root of inferior mesentery artery
Hartmann’s procedure is usually associated with
emergent settings, and therefore has a higher risk
of wound infection than elective surgery.
Laparoscopic Hartmann’s procedure has less
infection rate than conventional Hartmann’s pro-
cedure [10] however it still has 5–10% wound
infection rate. Adequate fluid drainage with anti-
biotic treatment for 7–10 days should be given
for patients with wound infection. Parastomal
infection needs specialized nursing care, treated
with adequate abscess drainage and antibiotic
therapy.
Fig. 6 Divide rectum by endocutter
Ureteral Injury
In the medial-to-lateral approach for sigmoid

colon mobilization during the surgery, a surgical
plane is made below inferior mesentery artery.
The left ureter and gonadal vessels should be
swept away and injury to these structures could
be avoided if the plane is accurate. Under ideal
conditions, a ureter can be identified by Kelly’s
sign, a visible vermiculation by direct press. A
precise dissection along the surgical plane avoids
Fig. 7 Proposed end-colostomy without tension
ureteral injury. However, in the emergent setting,
severe inflammatory change and adhesions result
ter to divide the bowel proximally and disin difficulty identifying ureter. Latrogenic ure-
tally (Fig. 6). teral injury has been documented at 0.3–1.5%
8. Make sure the proximal colon could reach incidence rate. Despite preventing ureteral injury
the proposed colostomy site without tension. by inserting a ureteral double-J stent before colon
Make a circular incision at the proposed resection remains controversial, it provides
colostomy site. Split rectus abdominis and immediate identification of ureteral injury. Once
pull out the proximal colon through the inci- the ureter is injured, immediate repair with ure-
sion (Fig. 7). teral stenting placement for 2 weeks avoids reop-
9. Enlarge the 12 mm camera port, set a wound eration [11]. Usually, the ureteral stent is removed
protector, and remove the specimen through after the ureter was tested and healed.
Urinary Bladder Injury neal cavity should be treated by percutaneous

drainage, either by echogram-guided or
Bladder injury is a rare complication during colon CT-guided. Obtain bacterial culture and blood
surgery, the incidence is less than 5% [11]. It is culture sampling and then give empiric antibiot-
associated with an infectious or inflammatory pro- ics until the pathogen was yielded in the labora-
cess. A Foley catheter insertion before surgery tory, usually 7–10 days of antibiotic treatment is
avoids potential trocar injury during surgery. adequate.
Urinary bladder injury is usually identified by
urine leakage during surgery, the most reliable
confirmation is a visible Foley catheter balloon in Post-OP Care
the bladder. Immediate repair with a Foley cathe-
ter left for 2 weeks is indicated. The Foley catheter Adequate fluid maintenance to keep hemody-
will be removed after cystogram is performed. namic status stable. Vasopressor therapy initially
targets a mean artery pressure of 65 mmHg.
Intravenous fluid can be tapered after the patient
Vessel Injury tolerates oral intake. Postoperative ileus is com-
mon after emergent colorectal surgery, it ranges
It is more common to see vessel injuries in lapa- from days to weeks. A nasogastric tube indwell-
roscopic Hartmann’s procedure than in other ing is helpful in poor gastric emptying. Remove
laparoscopic surgeries. Severe inflammation, nasogastric tube when the drainage gastric juice
infectious process, and adhesion are risk factors decreased, and on diet as soon as patients can tol-
that contribute to vessel injuries. Compare to tra- erate. Normalized bowel movement could be
ditional D3 dissection with vessel ligation at the observed by feces or gas retention in the colos-
root of inferior mesentery artery, it occurs more tomy bag.
often in vessel ligation along intermittent vessels Education on colostomy nursing care is
or marginal vessels. Immediately control the important for patients and their caregiver, usually
bleeding vessels by laparoscopic energic device their spouse or children. An enterostomal thera-
or end clips would be helpful. pist is essential for postoperative care in
Hartmann’s procedure. A comprehensive health
education avoids most of the complications of
Bowel Injury colostomy, such as poor appliance, parastomal
dermatitis, or dehydration. A patient could be
In diverticulitis or tumor perforation diseases, discharged after he/she is well-educated in colos-
small intestine or right-sided colon may adhere to tomy care.
the inflamed colon. Irrigate the peritoneal cavity
with warm saline copiously and gently separate
adhesion between bowel loops by grabbing a wet References
gauze to mimic incidentally bowel injuries.
Seromuscular tear of the bowel wall can be 1. Hartmann H. New procedure for the removal of can-
cers of the terminal part of the pelvic colon. 1921
repaired by suturing. 2. DeMaio EF, Naranjo C, Johnson P. Hartmann’s
Intra-abdominal abscess formation: pouch, the Hartmann operation, the Hartmann pro-
A few days after surgery, if persisted fever or cedure: an enigma of terminology. Surg Endosc.
positive peritoneal sign was noted, intra- 1996;10(1):81–2.
3. van de Wall BJM, Draaisma WA, Schouten ES,
abdominal abscess formation should be consid- Broeders IAMJ, Consten ECJ. Conventional and lapa-
ered. It can be diagnosed by abdominal echogram roscopic reversal of the Hartmann procedure: a review
or computed tomography (CT). Superficial of literature. J Gastrointest Surg. 2010;14(4):743–52.
abscess just beneath the wound can be drained by 4. Guerra F, Coletta D, Del Basso C, Giuliani G, Patriti
A. Conventional versus minimally invasive Hartmann
opening the wound. Deep abscess in the perito-
takedown: a meta-analysis of the literature. World J 8. Fleming FJ, Gillen P. Reversal of Hartmann’s proce-
Surg. 2019;43(7):1820–8. dure following acute diverticulitis: is timing every-
5. Vermeulen J, Mannaerts GHH, Weidema WF, Lange thing? Int J Color Dis. 2009;7
JF. Restoration of bowel continuity after surgery for 9. Barbieux J, Plumereau F, Hamy A. Current indi-
acute perforated diverticulitis: should Hartmann’s cations for the Hartmann procedure. J Visc Surg.
procedure be considered a one-stage procedure? 2016;153(1):31–8.
Colorectal Disease. 2009;11(6):619–24. 10. Celentano V, Giglio MC, Bucci L. Laparoscopic ver-
6. Bell C, Fleming J, Anthony T. A comparison of com- sus open Hartmann’s reversal: a systematic review and
plications associated with colostomy reversal versus meta-analysis. Int J Color Dis. 2015;30(12):1603–15.
ileostomy reversal. Am J Surg. 2005;4 11. Ferrara M, Kann B. Urological injuries dur-
7. Salem L, et al. Primary anastomosis or Hartmann’s ing colorectal surgery. Clin Colon Rectal Surg.
procedure for patients with diverticular peritonitis? 2019;32(03):196–203.
A systematic review. Colon Rectum. 2004;47(11):12.
Part V
Endocrine Surgery
Remote Access Endoscopic
Thyroidectomy
Introduction Contraindications
This technique makes use of incisions that is out- • Evidence of thyroid Cancer with nodal and
side the exposed neck requiring advanced laparo- extrathyroidal extension, Graves disease,
scopic skills. Because its scar is hidden, the substernal extension, and previous neck sur-
technique became attractive especially for gery [2].
females, but with issues with extensive dissection
from the remote access to reach the target organ.
Remote access is divided into two: Extracervical Preoperative Assessment
(Transaxillary, retro auricular, breast and chest
wall approach) and Cervical Approach (Video- • Ultrasound of Neck, Thyroid function test,
assisted central approach, lateral endoscopic, and Chest X-ray, 12 lead ECG, CBC, and Bleeding
anterior endoscopic approach) [1]. parameters.
Indications Instruments
• Patient factor—thin habitus because the • Trocars.

absence of fat on flap trajectory makes it eas- • Retractor for flap elevation.
ier to do dissection [2]. • 30° Endoscope.
• Thyroid factor—well circumscribed nodule • Tunneler.
≤3 cm, thyroid lobe <5–6 cm largest dimen- • Electrocautery with long tip.
sion, no evidence of thyroiditis on UTZ [2]. • Hemoclip.
• Approach—axilla and sternal notch distance • Suction-irrigator.
should be <15–17 cm for axillary approach [2]. • Needle driver.
• Ultrasonic shears.
• Maryland forceps.
• Retrieval bag.
• Two 10 mL syringes.
• Spinal needle.
M. B. Fuentes (*) ∙ R. Lutanco • Intraoperative nerve monitoring (IONM)
Department of Surgery, The Medical City, Pasig,
probe.
Manila, Philippines

https://doi.org/10.1007/978-981-19-3755-2_24
140 M. B. Fuentes and R. Lutanco
Cervical Approach Table 1 Indications and contraindications for MIVAT [4]

Indications Contraindications
ideo-Assisted Central Approach,
V Nodule not exceeding Presence of metastatic/
Gases or MIVAT (Minimally Invasive 35 mm (largest suspicious nodes in the
diameter) lateral neck compartment
Video-Assisted Thyroidectomy) Volume not exceeding Thyroid cancers located
25 cc via ultrasound very posteriorly
This technique widespread and well-studied Fit for level 6 Thyroiditis
endoscopic assisted thyroidectomy was devel- lymphadenectomy
oped by Miccoli et al. in 1998 and makes use of
1.5 cm incision at the sternal notch (Fig. 1).
Although considered as the least invasive of min- strap muscles medially. 10 mm optic port is
imally invasive thyroidectomy (MIT), still has placed on the medial border of SCM which has
the drawback of exposed scar [3]. Exposure of direct access to posterior aspect of the gland. CO2
linea alba using retractors and inserting a 5 mm insufflation at 8 mmHg to maintain working
30° endoscope as the endoscopic phase of the space. Same dissection steps for lobectomy are
procedure. Thyroid lobe is pulled caudally to utilized [1].
expose the upper pedicle and in cutting this pedi-
cle, Sonicision is preferred because of its size and
high power of coagulation. After the superior Anterior Endoscopic Approach
pole is freed, thyroid is pulled medially and using
Tuberculum of Zuckerkandl as landmark, Since the procedure uses midline access, bilateral
Recurrent Laryngeal Nerve (RLN) is identified dissection of the thyroid gland can be achieved.
and preserved. RLN should be followed and dis- 5 mm Optical trocar is placed above the supraster-
sected until its insertion into the larynx, finishing nal notch, while two 2 mm trocars and one 5 mm
the procedure with transection of the lobe at the trocar are placed at the superior medial border of
Berry ligament and closure of strap muscles and SCM. Same steps for lobectomy/total thyroidec-
hemostasis [4]. Below are the indications and tomy as mentioned in previous approach [1].
contraindications for the procedure (Table 1).
Extra-Cervical Approach
Lateral Endoscopic Approach
Trans-Axillary Approach
This approach is for unilateral lesions since it
uses the plane between Sternocleidomastoid This approach was first accounted for by Ikeda
muscle (SCM) and carotid sheath laterally and et al. in 2000, having a remarkable cosmesis with
a hidden scar at the axilla sparing the breast and
having direct access to the gland. The lateral
view with this approach has the advantage of
easy identification of RLN and parathyroid
glands; however, downside is clashing of instru-
ments that is positioned close to each other [2, 5].
Indications [3]
• Adenomatous goiter or follicular nodule w

max diameter < 6 cm.
• dx of benign nodule by FNAC.
• Tumors <15 mm and confined to thyroid
Fig. 1 Sternal notch incision gland, without LN mets and local invasion.
Remote Access Endoscopic Thyroidectomy 141
Position—patient supine, arm, and shoulder sected to create a wide midline neck access.
on vertical height with the neck slightly extended. Sternothyroid muscle has to be dissected from
The arm on the pathological side is positioned the superior pole using EBD and CO2 insufflation
cephalad and flexed above the head (Modified maintained at 4–9 mmHg [1, 6].
Ikeda’s position) or an alternative is positioning Surgical Resection—Middle thyroid vein is
the ipsilateral arm to the lesion to 180° cephalad divided using Harmonic scalpel. Superior pole is
[1] and to avoid brachial plexus injury, it was then pulled in inferomedial direction exposing
suggested to have a limited extension across superior thyroid vessels which are ligated, para-
elbow and shoulder joints [2]. thyroid identified and preserved. Traction at tra-
Incisions—place an imaginary line between cheoesophageal groove helps in RLN
sternal notch and axilla, an inferior limit of inci- identification but it is recommended to use IONM
sion that is directed posteriorly to hide the scar. A to assure its integrity. Inferior pole is released by
60° oblique line was drawn from thyrohyoid sealing the vessels and subsequent division of the
membrane to axilla, marking the superior border isthmus and removal of the specimen using endo-
of the incision. After infiltration of 10 mL of 1% bag. Closure once hemostasis is assured.
lidocaine with 1 in 200,000 adrenaline solution, a
5–6 cm vertical incision is made intersecting
oblique and anterior axillary line defining the Retro-Auricular Approach
inferior limit (Fig. 2). Tissue handling in the inci-
sion area is important to avoid keloid. Compared to transaxillary approach, retroauricu-
Working space—defined by the clavicular lar has the advantage of easier positioning,
head above the omohyoid that is parallel to the shorter distance to the target gland, elimination
superior pole of the thyroid. A subcutaneous flap of brachial plexus paralysis, and chest paraesthe-
is created using monopolar electrocautery along sia. However, issues with transient greater auric-
the subplatysmal plane up to the clavicle. ular nerve hyperaesthesia and the need for
Retractors are used to maintain the plane; after bilateral incisions for total thyroidectomy if
clavicle identification, the SCM heads are dis- needed [1, 3].
Indication—length and circumference of the
neck is a major determinant of good exposure,
short and slender being the best candidate.
Thyroid required to be benign lesions, small and
early-stage carcinoma, this with neck metastasis
but no gross extracapsular spread.
Instruments—retractors and self-retaining
retractors, suction, long tip electrocautery and
hemo clip, 30° endoscope, and ultrasonic
dissector.
Patient position—supine under GA (ET tube 6
to allow IONM) and head turned 30° away from
the side dissection.
Incisions—postauricular crease incision
extending to the occipital area below the hairline
and it is important to avoid acute angle incisions
to avoid flap necrosis.
Working space—a subcutaneous flap superfi-
cial to platysma is created with Metzenbaum
scissors superficial to the greater auricular nerve.
Fig. 2 Patient position and skin incision Dissection continues until the omohyoid is iden-
tified, this serves as a landmark for strap muscles Postoperative care—acoustic (perceptive
that will be a guide going to the central neck area scale, voice handicap index, fundamental fre-
[1, 6]. quency, and maximal vocal pitch) and functional
Plane of dissection for flap is above the SCM evaluation (swallowing, pain/sensory, and cos-
fascia, Great auricular nerve and external jugular mesis) are done postoperatively at 1 week,
vein are identified and preserved. Flap dissection 1 month, 3, 6, and 12 months.
is continued until the anterior border of SCM.
Borders of dissection are submandibular
gland superiorly, midline of the neck anteriorly, Breast Approach
and sternal notch inferiorly. Anterior border of
SCM is retracted posteriorly to expose the A technique developed by Ohgami et al. in 2000,
carotid sheath, followed by identification and makes use of two 15 mm circumareolar incisions
dissection of omohyoid and strap muscles which and another 5 mm at 3 cm below the ipsilateral
are both retracted superiorly to expose the supe- clavicle. 12 mm trocar is inserted to create the
rior pole of the thyroid (Fig. 3). The same proce- working space. Then proceed with dissection like
dure for conventional thyroidectomy, bear in the open thyroidectomy but will begin at the
mind that RLN is noted to be in a higher posi- inferior pole and then goes posterolaterally to
tion than expected because of the medial reac- expose the gland [2, 3].
tion of the gland. This technique has two different approaches:
Complications—hypothyroidism, temporary
corner of the mouth deviation (indirect injury to xillo-Bilateral Breast Approach
A
marginal mandibular nerve), and transient ear- (ABBA)
lobe numbness (indirect injury to great auricular Was first introduced by Shimazu et al. He modi-
nerve) all managed conservatively. Minor com- fied incision to resolve the issues of narrow view
plications such as hematoma or skin flap necro- and limited mobility using an axillary instead of
sis, hair loss along the incision line, wound the previous parasternal incision. This allowed
infection and keloid are encountered. better cosmesis, easy identification of structures
from the lateral view, and provides freedom of
movement accounting for shorter operative time
[3, 5, 7].
Indication:
• Low risk thyroid carcinoma not large than

1 cm,
• Follicular neoplasm <3 cm,
• Benign thyroid nodules.
OT Setup:
Patient position: supine, ipsilateral arm
extended to expose the axilla.
Incisions: Subcutaneous epinephrine-saline
solution injection of anterior chest wall and
working space in the subplatysmal area done
(hydrodissection—makes the dissection easy
and decreases bleeding). A 2.5 cm incision was
made at the level of skin crease of the ipsilateral
axilla. Using the tunneler, blunt dissection of
Fig. 3 To expose thyroid gland: SCM retracted posteri- skin from pectoralis muscle was done and a
orly and omohyoid and strap muscles superiorly 12 mm trocar was inserted. Succeeding two
Fig. 4 Landmarks for dissection
5 mm trocars placed on the ipsilateral and con-

tralateral upper circumareolar area and blunt
dissection towards the sternal notch done. After
the creation of working space, insufflation was
done with CO2 gas at 6 mmHg at the 12 mm
port. Once the landmark for dissection such as
anterior border of SMC is identified we then
proceed with freeing the thyroid gland from
sternohyoid and Sternothyroid muscles (Fig. 4).
Control of superior, middle, and inferior thy-
roid vessels using Harmonic scalpel, staying as
close to the glands possible to avoid injury to
external branch of superior laryngeal nerve and
RLN [3, 7].
ilateral Axillo-Breast Approach

B
(BABA) Fig. 5 Port placement
Developed in 2007 by Choe et al. as a modifi-
cation of Shimazu’s ABBA technique with
addition of contralateral axillary port. This The 8–12 mm ports are placed on both supero-
technique has the advantage of having a sym- medial circumareolar incisions while two axil-
metrical view of both lobes, is more ergo- lary incisions for instruments were made as 5 mm
nomic, and allows central node dissection. It port (Fig. 5). The same steps for subcutaneous
also prevents the clashing of instruments with dissection are carried out for endoscopic thyroid-
its large operative angles as compared to the ectomy breast approach [2].
other remote access approaches [2, 3, 6].
Although this is an appealing technique,
patients who have breast implants will be an Complications
extra challenge for the surgeon. They have to
deal with smaller space and the possibility of 1. Hematoma can be prevented by adequate
implant rupture. Other surgeons also consid- hemostasis but if there are early signs of air-
ered this technique quite invasive due to extent way compromise, one can do reexploration
of the dissection [5]. and evacuation of blood clots.
2. Nerve injury (RLN, mandibular nerve, exter- is used. Lens should be withdrawn and use
nal branch of SLN, and brachial plexus) is aspirator for continuous smoke evacuation.
avoided by mastery of anatomy and identifi- • RLN injury—good exposure to RLN is the
cation of structures during dissection. key and is done by pulling strap muscles later-
Permanent palsies lasting for 12 months is ally. If available in your institution, you may
noted to be at .3–3% of cases. It is standard use IONM. During dissection at the area of
practice to use IONM in thyroidectomy to ligament of Berry, move a few mm away when
prevent this kind of complication [1]. Brachial using ultrasonic shears.
plexus neuropraxia can be prevented by cau-
tious positioning of ipsilateral arm. Transaxillary Approach
3. Hypoparathyroidism can be transient and per- Brachial plexus injury: modification of arm posi-
manent (hypocalcemia >6 months) for total tioning and use of brachial plexus monitoring.
thyroidectomy patients. Patients are given
oral Calcium supplement upon discharged
and adjusted according to serum Calcium lev- References
els on follow-up [1].
4. Seroma. 1. Bhatia P, Mohamed HE, et al. Remote access thyroid
surgery. Gland Surg. 2015; https://doi.org/10.3978/j.
5. Wound infection. issn.2227-684X.2015.05.02.
2. Berber E, Bernet V, et al. American thyroid association
statement on remote-access thyroid surgery. Thyroid.
Postoperative Care 2016; https://doi.org/10.1089/thy.2015.0407.
3. Sephton BM. Extracervical approaches to thyroid
surgery: evolution and review. Minimally Invasive
• Patient is seen after 1 week and 3 months post- Surgery. 2019; https://doi.org/10.1155/2019/5961690.
operatively [2]. 4. Miccoli P, Fregoli L, et al. Minimally invasive video-
assisted thyroidectomy (MIVAT). Gland Surg. 2019;
https://doi.org/10.21037/gs.2019.12.05.
5. Aidan P, et al. Gasless trans-axillary robotic thyroid-
Tips [8] ectomy: the introduction and principle. Gland Surg.
2017; https://doi.org/10.21037/gs.2017.03.19.
Areolar Approach 6. Russell J, Noureldine S, et al. Minimally invasive
and remote access thyroid surgery in the era of the
• The short distance between optics and instru- 2015 American Thyroid Association guidelines.
ments interferes with the view: adjust the inci- Laryngoscope investigative Otolaryngology. 2016;
sions (if areola is small, make incisions a few https://doi.org/10.1002/lio2.36.
mm distant from the other incision). 7. Hong HJ, Kim WS, et al. Endoscopic thyroidectomy
via axillo-breast approach without gas insufflation for
• Ecchymosis: plane should be between deep benign thyroid nodules and micropapillary carcino-
and superficial fascia and between subplatys- mas: preliminary results. Yonsei Med J. 2011; https://
mal and deep cervical fascia. doi.org/10.3349/ymj.2011.52.4.643.
• Subcutaneous emphysema: maintain CO2 at 8. Jia G, Tian Z, et al. Comparison of the breast and
areola approaches for endoscopic thyroidectomy in
6 mmHg pressure. patients with microcarcinoma. Oncol Lett. 2017;
• Smoke: clear operative field is affected by https://doi.org/10.3892/ol.2016.5439.
plume when electrocautery or ultrasonic device
Transoral Endoscopic
Thyroidectomy
Introduction comes into favor because it makes use of natu-

rally predetermined cervical layers that can be
With the advancement in different MIS proce- bluntly separated rather than divided and leave
dures across subspecialties, endocrine surgeons no visible scars [3, 4]. Learning curve studies
convene and embark on improving thyroidec- were conducted to investigate surgeon’s profi-
tomy techniques adhering to proper management ciency in learning the new technique. It was
of thyroid pathology while achieving optimal noted to be 11 cases of endocrine surgeons who
cosmetic result and safety [1, 2]. had no considerable training with laparoscopic
In 2007, New European Surgical Academy procedures done by Razavi et al. [5] while Lee
had an interdisciplinary assembly on NOTES on et al., believed that the learning curve should
various procedures including the thyroid sec- stabilize only after 20 procedures [6].
tion. It emphasized on the criteria for minimally
invasive endoscopic thyroidectomy which is
respecting surgical planes, minimizing trauma, volution of Transoral Endoscopic
E
requiring access to be as close as possible to the Thyroidectomy
gland, optimal cosmesis, and safety.
Investigations on evolving techniques were Sublingual Approach
done to evaluate its safety and clinical applica-
tion. They observed that Totally Transoral The idea was started using cadavers and pigs by
Video-assisted thyroidectomy (TOVAT) has Witzel et al., using a single 10 mm sublingual
serious concerns on safety and application due incision with addition of two 3.5 mm located at
to the important structures that are prone to external neck for triangulation of rigid instru-
injury at the submandibular triangle once tro- ments used [7].
cars are inserted. Transoral vestibular approach
ombined Sublingual and Oral

C
Vestibular Approach
Another simulation done by Benhidjeb et al.,

introduced the transoral video-assisted thyroid-
M. B. Fuentes (*) ∙ R. Lutanco ectomy (TOVAT) on human cadavers and makes
Department of Surgery, The Medical City, use of one 5 mm and two 3 mm trocars at the
Pasig, Manila, Philippines floor of the mouth and oral vestibule [7, 8].
https://doi.org/10.1007/978-981-19-3755-2_25
Oral Vestibular Approach Table 1 (continued)

Modifications for Robotic
Richmond et al. first described oral vestibular Inclusion Criteria TOETVA
approach with assistance of the robot (Transoral 1° papillary Papillary Ca with
microcarcinoma minimum extra thyroidal
robotic-assisted thyroidectomy-TRAT) and con- without local/distant extensions (T1, T2, and
cluded that using oral vestibule for optics is bet- metastasis T3)—papillary CA with or
ter. Another modification of the technique was without evidence of
designed by Nakajo et al. (Transoral video- cervical lymph node
metastasis (N0, N1a)
assisted neck surgery—TOVANS) a single
Patient request Grave’s disease with
25 mm incision at the center of oral vestibule volume of ≤50 mL
combined with the gasless technique by using
Kirschner wire as an external retractor to main-
tain working space [9] while Wang et al., com- Contraindications
bined the three transoral incisions and make use
of CO2 insufflation in maintaining the working TOETVA is suitable for most thyroid cancers but
space [7]. With an increasing interest in this not for those with extensive extrathyroidal inva-
promising procedure, Dr. Angkoon who has the sion and lateral neck metastasis, patients who can-
most number of cases, modified the incisions on not tolerate general anesthesia, previous radiation
the oral vestibule placing the two lateral ports in in head and neck and upper mediastinum, previous
between the incisor and canine thus avoiding neck surgery, recurrent goiter, UTZ findings: vol-
mental nerve injury—Transoral endoscopic thy- ume ≥ 45 mL, nodule >5 cm, documented node/
roidectomy vestibular approach (TOETVA). distant metastasis, tracheal and esophageal infil-
tration, preoperative laryngeal palsy, hyperthy-
roidism, mediastinal goiter, oral abscess and
Indications poorly differentiated cancer, dorsal extra thyroidal
radius and lateral neck metastasis [12].
For beginners, it is suggested to start with female
patients with uncomplicated right lobectomy
since the majority of surgeons are right-handed Preassessment
and to avoid male patients for the main reason
that the thyroid cartilage interferes with vision All patients need to have routine thyroid function
and dissection [10].To standardize the Criteria tests, neck ultrasound, and fine needle aspiration
for the procedure as seen in Table 1, an biopsy. Direct laryngoscopy is done a day before
International Transoral Neck Surgery (TONS) surgery to document palsy. Oral cavity prepara-
Study Group conference was held and consensus tion is done using 0.05% Hibitane H2O 5 min and
for modifications, preparation, techniques, and IV antibiotic 1.2 g Amoxicillin+Clavulanic acid
postoperative care for patients was reached [11]. given 30 min prior to incision [11].
Table 1 Inclusion criteria Operative Setup

Modifications for Robotic
Inclusion Criteria TOETVA
Instruments
Ultrasound: Gland
size– < 10 cm
Volume– < 45 mL • 30° scope 10 mm/5 mm
Nodule size– < 5 cm • Tissue grasper
Histopathologic: • Needle holder
Bethesda 3 or 4 • Vascular clips
Transoral Endoscopic Thyroidectomy 149
• Veress needle mouth, neck, and lower face prepped and draped.
• Maryland dissector (Fig. 2)
• Energy-based device (EBD) The surgeon at the head area of the patient
• Trocars: 1 (10 mm) and 2 (5 mm) with full view of the oral cavity and monitor and
• Kelly clamp assistants on the side of the patient.
• Endobag
• Straight vascular tunneler (Fig. 1)
• Ball-tip stimulator Intraop Neuromonitoring Surgical Technique
probe (IONM) 230 mm long
1. Working space creation: first 10 mm incision
is made at the center of the oral vestibule just
Patient Position above the inferior labial frenulum, Kelly
clamp is tunneled through the chin until sub-
Patient is placed on supine,15° Trendelenburg mandibular area is reached. Long Veress nee-
position, neck slightly extended using shoulder dle is used for hydrodissection (30 mL
pad and feet toward the monitor [1, 13]. solution of 1 mg of adrenaline diluted with
Nasotracheal intubation fixed at the corner of the 500 mL normal saline) to expose the subpla-
tysmal flap, the oral vestibular area of lower
lip down to anterior neck and laterally to the
central working space (Fig. 3) [1, 11, 13].
2. Port placements: Blunt-tip tissue dissector is
inserted at the central incision, advancing
about 2 cm distally to the chin in a fan-shaped
manner to widen the working space followed
by introduction of 10 mm trocar (Fig. 4) [11].
Insufflation was maintained at 6 mmHg and
CO2 with 15–20 mL/min flow rate to avoid
subcutaneous emphysema. The two lateral
5 mm trocars are placed at the junction
between incisor and canine on both sides and
just in the inner aspect of inferior lip to avoid
mental nerve injury.
Fig. 1 Straight vascular tunneler
Fig. 2 Extended neck position

3. Borders: Superior border is the larynx, inferi- Thyroid vessels are ligated and divided in
orly by suprasternal notch and both sterno- sequence starting with the middle thyroid vein
cleidomastoid muscles laterally (Fig. 5). followed by the superior thyroid vessels.
4. A 30°, 10 mm endoscope inserted, on a cra- During dissection, upper pole is lifted up to
niocaudal view, strap muscles are divided and improve the identification of recurrent laryn-
retracted laterally. Isthmus is divided expos- geal nerve (RLN) especially in dissection near
ing the trachea while the strap muscles are the ligament of Berry. IONM is performed
dissected from thyroid lobes. External hang- using stimulation level 3 mA, location of RLN
ing sutures can be laid at this time for addi- is evaluated while doing blunt dissection to
tional mechanical retraction (optional). explore the RLN at its entry point and traced
inferiorly using IONM forceps [1, 7, 8, 11,
14] Different IONM stimulators were chosen
according to purpose; if RLN location is to be
evaluated, a high level (3 mA or more) is
appropriate while a low level (1 mA) may be
used for identification and confirmation of its
integrity. After dissecting the thyroid capsule
away from RLN, ligament of Berry’s was
identified and divided using harmonic scalpel
while preserving the parathyroid glands. The
thyroid lobe was lifted medially and lower
Fig. 3 Hydrodissection with veress needle to expose the
pole was identified and divided from perithy-
flap
Fig. 4 Creating subplatysmal flap using tunneler

Transoral Endoscopic Thyroidectomy 151
Postoperative Care
No dressing is required but oral antibiotic and

mouthwash are prescribed three times a day for
5–7 days. Patient is allowed to have a soft diet in
the same evening of surgery. Hospital discharge
depends on the result of postoperative direct
laryngoscopy and serum Ca (if total thyroidec-
tomy is done).
Fig. 5 Borders of dissection

Tips and Tricks
roidal tissues. The specimen was placed in the • Identification subplatysmal plane—each
endocatch bag and removed through 10 mm patient has a varied thickness, decussations,
incision. Meticulous hemostasis was done shape, and size, when not identified will go
prior to strap muscle approximation with 3–0 through the strap muscles or even deeper caus-
absorbable sutures. The same technique was ing subcutaneous emphysema worst pneumo-
applied to contralateral side for total thyroid- mediastinum [9].
ectomy [1, 6, 9, 13, 14]. • Subcutaneous emphysema/Pneumomediasti
num—CO2 insufflation should be strictly
maintained at 6 mmHg pressure with
Complications and Management 15–20 mL/min flow rate.
1. Hypoparathyroidism—seen in 5.6% of cases

which could be prevented by parathyroid References
gland angiography with indocyanine green
(ICG). The transient hypoparathyroidism can 1. Fernandez-Ranvier G, Meknat A, et al. Transoral
endoscopic thyroidectomy vestibular approach. J Soc
be managed by giving calcium and vitamin D Laparoendosc Surg. 2019; https://doi.org/10.4293/
supplementation [6]. JSLS.2019.00036.
2. RLN injury—seen in 3.1% of cases hence 2. Witzel K, Hellinger A, et al. Endoscopic thyroid-
IONM is required during dissection especially ectomy: the transoral approach. Gland Surg. 2015;
https://doi.org/10.4293/JSLS.2018.00026.
if total thyroidectomy is contemplated [3]. 3. Chen S, Zhao M, et al. Transoral vestibule approach
3. Mental nerve injury—is seen in 1.5% which for thyroid disease: a systematic review. Eur Arch
lead to modification of incision at the vestibu- Otorhinolaryngol. 2018; https://doi.org/10.1007/
lar area. s00405-018-5206-y.
4. Benhidjeb T, Stark M, et al. Transoral thyroidec-
4. Subcutaneous emphysema was observed tomy–from experiment to clinical implementation.
when the CO2 pressure was increased to more Transl. Cancer Res. 2017; https://doi.org/10.21037/
than 6 mmHg. With conservative manage- gs.2017.03.16.
ment, subcutaneous emphysema has gradual 5. Razavi C, Vasiliou E, et al. Learning curve
for transoral endoscopic thyroid lobectomy.
reabsorption in 6–12 h although 48 h is needed Otolaryngol Head Neck Surg. 2018; https://doi.
to achieve complete resolution [6, 9]. org/10.1177/0194599818795881.
5. Minor complications like seroma (2.5%), 6. Wang Y, Yu X, et al. Implementation of intraopera-
hematoma, and infection which were conser- tive neuromonitoring for transoral endoscopic thy-
roid surgery: a preliminary report. J Laparoendosc
vatively managed.
Adv Surg Techn. 2016; https://doi.org/10.1089/ 11. Anuwong A, Sasanakietkul T, et al. Transoral endo-
lap.2016.0291. scopic thyroidectomy vestibular approach (TOETVA):
7. Anuwong A, Kim HY, et al. Transoral endoscopic indications, techniques and results. Surge Endosc.
thyroidectomy using vestibular approach: updates 2017; https://doi.org/10.1007/s00464-017-5705-8.
and evidences. Gland Surg. 2017; https://doi. 12. Dionigi G, Chai YJ, et al. Transoral endoscopic
org/10.21037/gs.2017.03.16. thyroidectomy via vestibular approach: why and
8. Nakajo A, Arima H, et al. Trans-oral video-assisted how? Endocrine. 2017; https://doi.org/10.1016/j.
neck surgery (TOVANS). A new transoral technique ijscr.2018.07.018.
of endoscopic thyroidectomy with gasless pre- 13. Dionigi G, Bacuzzi A, et al. Transoral endo-
mandible approach. Surg Endosc. 2013; https://doi. scopic thyroidectomy: preliminary experience in
org/10.1007/s00464-012-2588-6. Italy. Updat Surg. 2017; https://doi.org/10.1007/
9. Zhang D, Che-Wei W, et al. Lessons learned from a s13304-017-0436-x.
faulty transoral endoscopic thyroidectomy vestibu- 14. Erol V, Dionigi G, et al. Intraoperative neuromonitor-
lar approach. Surg Laparosc Endosc Percutan Tech. ing of the RLNs during TOETVA procedures. Gland
2018;28:e94–9. Surg. 2020; https://doi.org/10.21037/gs.2019.11.21.
10. Zhang D, Sun H, Anuwong A, et al. Indications,
benefits and risks of transoral thyroidectomy. Best
Pract Res Clin Endocrinol Metab. 2019; https://doi.
org/10.1016/j.beem.2019.05.004.
Laparoscopic Adrenalectomy
Abdominal Approach
Introduction Indications
Since its first description by Gagner et al., in More than 75% of LA’s are performed for endo-
1992, laparoscopic adrenalectomy has become crine causes of hypertension such as aldoster-
the gold standard for the surgical treatment of onoma, Cushing’s syndrome and disease, and
most adrenal conditions [1]. It has generally pheochromocytoma. Other indications adrenal
replaced open adrenalectomy for small- and cyst, metastases, myelipoma, primary adrenocor-
medium-sized adrenal lesions [2]. The advantages tical neoplasm, androgen-secreting tumors, adre-
of LA include shorter hospital stays, less postop- nal hemorrhage, ganglioneuroma, and adrenal
erative pain, and better cosmetic results [3]. tuberculosis [5] (Table 1).
The lateral transabdominal approach to the Adrenalectomy is generally indicated in the
adrenals is currently one of the most widely used following:
technique. It allows an optimal comprehensive
view of the adrenal region and surrounding struc- • Biochemically functioning tumors.
tures and provides adequate working space [4]. • Suspected primary adrenal malignancies.
The magnification of the endoscope is particularly
helpful in the course of dissection in this area. A Careful consideration of the imaging charac-
detailed knowledge of retroperitoneal anatomy teristics of the lesion (CT/MRI/PET-CT) should
with gentle tissue manipulation and precise hemo- be done to assist in decision-making.
static technique are essential requirements for a
successful laparoscopic adrenalectomy.
Contraindications
Absolute contraindication to LA are patients who

H. Chua (*) are unable to tolerate laparoscopy.
Section of Minimally Invasive Surgery, Cebu Relative contraindications to laparoscopy
Doctors’ University Hospital, Cebu, Philippines
include presence of locally invasive tumors that
Advanced Minimally Invasive Surgery Fellowship require contiguous resection of other structures,
Program, Cebu Doctors’ University Hospital,
Cebu, Philippines persistent coagulopathy, and inability to perform
the procedure safely with minimally invasive
V. M. Roble II
Advanced Minimally Invasive Surgery Fellowship techniques.
Program, Cebu Doctors’ University Hospital, The size limit to consider LA has been
Cebu, Philippines increased progressively from 6 cm, to 8 cm, and
https://doi.org/10.1007/978-981-19-3755-2_26
154 H. Chua and V. M. Roble II
Table 1 Indications and contraindications for laparoscopic adrenalectomy [6]

Indications Relative contraindications Absolute contraindications
• Functional unilateral benign adrenal • Functional or nonfunctional unilateral • Functional or nonfunctional
mass (<6–10 cm) benign adrenal mass (10–15 cm) unilateral benign adrenal
• Nonfunctional unilateral benign • Malignant adrenal mass (small, mass (>15 cm)
adrenal mass (>4 cm, lesion growth, or encapsulated, noninvasive) • Invasive malignant adrenal
concern for malignancy • Previous nephrectomy, splenectomy, mass
• Primary unilateral adrenal hyperplasia and/or hepatectomy.
• Unilateral adrenal metastasis • Surgeon inexperience with
laparoscopic adrenalectomy
to 10–12 cm, depending on the experience of the 6. Anti-thrombotic stockings are placed prior to
surgical team [7]. Large adrenal tumors have a induction of anesthesia and a sequential com-
higher malignant rate. Sturgeon et al. discovered pression device is utilized.
more malignant incident rate of large adrenal 7. Foley catheters are placed in patients with
tumor (<4 cm = 5%, > or = 4 cm = 10%, larger tumors or more difficult cases.
and > or = 8 cm = 47%) [8]. Intraoperative find- 8. Cross-matched blood should be prepared for
ings, rather than strict reliance on tumor size, vascular tumors or tumors with invasion.
should determine whether a patient undergoes
laparoscopic versus open adrenalectomy for
adrenal cortical tumors [9]. Operating Theater Setup
Instrumentation [10]
Preop Preparation [6]
• Veress needle.
1. Blood pressure control and correction of elec- • 10 mm 30 and 0 laparoscopes.
trolyte abnormalities are done preoperatively • 5 mm 30 and 0 laparoscopes.
in patients with functional adrenal mass and • One 12 mm and three (left) or four (right)
hypertension. 5 mm non-bladed trocar.
2. All patients with hypercortisolism should • 5 mm Suction Aspirator (Stryker, Kalamazoo,
receive intravenous stress-dose corticoste- MI).
roids and are given immediately before and • Ultrasonic curved shears—Harmonic scalpel
after adrenalectomy. (Ethicon Endosurgery, Cincinnati, OH).
3. For patients with pheochromocytoma, alpha • Laparoscopic scissors.
adrenergic receptor blockade is started • 5-mm right angle forceps.
7–10 days prior to surgery. The goal is to • Graspers-locking and non-locking [2].
achieve control of hypertension and achieve • Bipolar forceps (Aesculap or Wolf).
mild orthostasis. Beta adrenergic blockade • 5 mm polymer locking clip and applier (Hem-
should be initiated if tachycardia persists, or O-Lok-Weck, NC).
the tumor is epinephrine secreting. • 10 mm specimen retrieval bag (Ethicon or US
4. Close discussion with the anesthetist team in Surgical).
the preparatory phase is important, particu- • PEER retractor (Jarit, Hawthorne, NY).
larly in the hemodynamic management of • Diamond-Flex triangular retractor (Snowden-
patients with pheochromocytoma. Pencer, Tucker, GA).
5. Preoperative antibiotic prophylaxis is • Optional: 5 mm Ligasure laparoscopic forceps
administered prior to the beginning of the (Valleylab, Boulder, CO).
procedure. • Optional: Carter Thomasson Inlet Closure
device (Inlet Medical, Eden Prairie, MN).
Laparoscopic Adrenalectomy Abdominal Approach 155
Patient Position [10] Port Placement
Patient is placed in a lateral decubitus position Right Adrenalectomy [6]

with the affected side elevated around 60°. A
bean bag is placed to help support the patient in 1. Mark the anterior and posterior axillary lines
the required position. Axillary pads are placed before prepping the patient
under the contralateral axilla and the arms are 2. Open technique is the preferred approach on
secured with padding. The patient is securely fas- entering the abdominal cavity using a blunt
tened with adequate padding to the operating tipped cannula. Access to the peritoneal cav-
room table using tape over the leg, thigh, pelvis, ity may also be done using a closed technique
and chest. Flex the operating table to increase with a Veress needle.
flank exposure (Fig. 1). Position the video moni- 3. Insert first 10 mm trocar along anterior axil-
tors near the patient’s head. The surgeon and first lary line two fingers’ breadths below the cos-
assistant stand on the abdominal side of the tal margin.
patient. The second assistant stands on the side of 4. The endoscope is then inserted and a diagnos-
the patient’s back (Fig. 2). tic laparoscopy is performed. Look for signs
of local invasion.
5. Under direct vision, insert second 5 mm trocar
in the subcostal area medial to the first trocar.
This port is for the graspers, energy devices,
and peanut swabs used for dissection.
6. Insert the third 5 mm trocar between the ante-
rior axillary line and the epigastrium. This
will be used to retract the liver.
7. Insert the fourth 5 mm trocar at the subcostal
triangle.
Left Adrenalectomy [6]

Fig. 1 Patient positioning
1. Mark the anterior and posterior axillary lines

before prepping the patient.
2. Access peritoneal cavity using closed tech-
nique with Veress needle. Open technique
may also be used using a blunt tipped
cannula.
3. Insert first 10 mm trocar along anterior axil-
lary line two fingers’ breadths below the cos-
tal margin.
4. The endoscope is then inserted and a diagnos-
tic laparoscopy is performed. Look for signs
of local invasion.
5. Two other 5 mm trocars are placed under
direct vision about 7 cm on each side of the
first trocar below the costal margin.
6. The fourth trocar, when necessary, is posi-
tioned below the first trocar at a distance of
Fig. 2 Surgical team position [11] 4–5 cm.
Surgical Technique [6] 6. The adrenal is then lifted up and the posterior,
lateral, superior aspect of the gland is dis-
Right Adrenalectomy sected (Fig. 6).
7. Identify and divide the three main adrenal
Right Adrenalectomy is potentially more hazard- arteries and accessory veins with energy
ous than left adrenalectomy due to the anatomy
of the adrenal vein and its drainage to the inferior
vena cava. Dissection of the right adrenal gland
involves meticulous dissection of the lateral bor-
der to the inferior vena cava.
1. After pneumoperitoneum has been estab-

lished, a 5 mm retractor is inserted through
the most medial subcostal port to elevate the
right lobe of the liver.
2. The right triangular ligament is dissected to
achieve partial mobilization of the liver.
Incise the posterior peritoneum along the
inferior margin of the liver to expose the Fig. 4 Dissection of medial border of the gland
adrenal gland. The liver is then retracted
upwards and medially to expose the adrenal
gland and the inferior vena cava. The plane
between the medial edge of the adrenal
gland and the inferior vena cava is dissected
(Fig. 3).
3. Dissection of the lateral edge of the vena cava
should start from the right renal vein and head
superiorly.
4. Identify the right adrenal vein. Dissect with
right angle forceps and is doubly clipped and
divided (Fig. 4).
5. Proceed to dissection of the inferior aspect of
the adrenal en bloc with the periadrenal fat
Fig. 5 Isolation of R adrenal vein
(Fig. 5).
Fig. 3 Division of right triangular ligament Fig. 6 Dissection of the posterior aspect of the adrenal
Fig. 7 Placement of adrenal within a retrieval bag Fig. 8 Dissection of the splenorenal ligament
devices. Typically, the adrenal arteries are not

prominent and may not be intentionally
identified.
8. Place the adrenal within a retrieval bag and
remove it through the 10 mm trocar (Fig. 7).
9. Drain placement is optional. Port site closure
is done.
Left Adrenalectomy Fig. 9 Medial rotation of the pancreatic tail
Several factors such as the lack of a major ana-

tomic landmark, relatively small size of the left
adrenal gland, main vein within the retroperi-
toneal fat, and close proximity to the pancre-
atic tail may render left adrenalectomy a
challenging procedure. Careful dissection and
mobilization of adjacent organs such as the
spleen and pancreatic tail are needed to avoid
injury.
1. Mobilization to the splenic flexure. Fig. 10 Identification of the adrenal gland

2. Division of the splenorenal ligament and
rotate the spleen medially (Fig. 8). 6. Visualize the left renal vein during medial
3. Dissect the plane between the kidney and the dissection and elevate the adrenal gland from
tail of the pancreas and medially rotate the this vessel.
pancreas (Fig. 9). 7. Identify the left adrenal vein running
4. Identify the adrenal gland near the superior obliquely from the inferomedial aspect of the
and medial aspect of the kidney (Fig. 10). adrenal gland to its junction with the left
5. Identify the medial and lateral borders of the renal vein. Isolate and doubly clip and divide
gland and follow these borders caudally to (Fig. 11).
the inferior margin of the gland where the 8. Completely dissect the adrenal gland from
adrenal vein lies. the surrounding tissue.
Most patients are discharged after 24–48 h

without restrictions to physical activities. Patients
may return to work within 7–14 days. A follow-
up exam at the office should be performed

2–3 weeks after discharge. Patients are generally
advised to avoid strenuous activities for
2–4 weeks.
For patients with hypercortisolism and those
who undergo bilateral adrenalectomy, intrave-
nous stress-dose corticosteroids are given in the
Fig. 11 Identification of the L adrenal vein
immediate perioperative period. Once the patient
resumes diet, intravenous doses may be stopped
and replaced with oral corticosteroid therapy.
Patients with Cushing syndrome may require
replacement therapy for 6–12 months while the
contralateral gland recovers. This may be gradu-
ally tapered off as tolerated.
Complications
Complication rate for laparoscopic adrenalec-

Fig. 12 Placement of specimen in a retrieval bag tomy ranges from 2.9% to 15.5% [7].
9. Visualize and ligate with clips or with energy Hemorrhage [12]

device arterial branches of the renal artery. Bleeding is the most prevalent intra-op and post-
The small adrenal arteries may not be easily op complication considering the gland is highly
identified but these are divided with the vascularized and adjacent to major blood vessels.
energy devices during the dissection of the Intraoperative hemorrhage can be easily identified
adrenal gland. and may require conversion to an open procedure
10. Place the adrenal within a retrieval bag and if hemostasis cannot be achieved. Postoperative
remove it through the 10 mm trocar (Fig. 12). bleeding is best detected by monitoring vital
11. Drain placement is optional. Port site closure signs, urine output, and physical diagnosis of the
is done. abdomen.
Organ Injury [11]

Post-op Management [6] The key to the prevention of inadvertent organ
injury is familiarity with the anatomy and gentle
Most patients can be admitted to a regular surgi- dissection. Damage to the liver and spleen will
cal nursing unit. Patients with hemodynamically present as intraoperative bleeding.
significant pheochromocytoma or major underly- Care should be taken while dissecting the
ing cardiopulmonary disease should be admitted superior aspect of the left adrenal gland to pre-
to an intensive care unit. vent injury to the pancreatic tail. Damage to the
Diet may be advanced as tolerated. Oral anal- pancreas can present early as pancreatitis or late
gesics may be taken 24 h postoperatively. A com- as pancreatic pseudocyst. These can be self-
plete blood count and metabolic panel may be limited but may require medical or surgical
drawn as clinically indicated. management.
High dissection in the abdomen may cause 3. Gill I. The case for laparoscopic adrenalectomy. J
Urol. 2001;166:429–36.
diaphragmatic injury, potentially leading to a ten- 4. Raffaelli M, De Crea C, Bellatone R. Laparoscopic
sion pneumothorax. Closure with chest drainage Adrenalectomy. Gland Surg. 2019:S41–52.
would be the appropriate solution. 5. Mckinlay R, Mastrangelo M, Park A. Laparoscopic
adrenalectomy: indications and technique. Curr Surg.
2003;60:145–9.
Others [11] 6. Bittner JG, Brunt L. Laparoscopic adrenalectomy.
Appropriate pharmacologic blockade is manda- New York: Lippincott Williams & Wilkins; 2013.
tory before surgery of pheochromocytoma to pre- 7. Gumbs A, Gagner M. Laparoscopic adrenalectomy.
vent hypertensive crisis intraoperatively. Best Pract Clin Endocrinol Metab. 2006;20:483–99.
8. Duh QY. Laparoscopic adrenalectomy for isolated
Hemodynamic instability particularly hyperten- adrenal metastasis: the right thing to do and the right
sive and hypotensive episodes (post-excision of way to it. Ann Surg Oncol. 2007:3288–9.
tumor) may occur after laparoscopic adrenalec- 9. Sturgeon C, Kebebew E. Laparoscopic adrenal-
tomy for pheochromocytoma. Sufficient hor- ectomy for malignancy. Surg Clin North Am.
2004;83(4):755–74.
monal replacement is mandatory after bilateral 10. Mellon MJ, Sethi A, Sundaram CP. Laparoscopic
adrenalectomy in Cushing’s disease. adrenalectomy: surgical techniques. Indian J Urol.
2008:583–9.
11. Assalia A, Gagner M. Laparoscopic adrenalectomy.
In: Scott-Conner CE, editor. The SAGES manual,
References fundamentals of laparoscopy, thoracoscopy, and gi
endoscopy. New York: Springer; 2006. p. 252–464.
1. Tsuru N, Suzuki K. Laparoscopic adrenalectomy. J 12. Brunt L. The positive impact of laparoscopic adre-
Minim Access Surg. 2005:165–72. nalectomy on complications of adrenal surgery. Surg
2. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenal- Endosc. 2002;16:252–7.
ectomy in Cushing’s syndrome and pheochromocy-
toma. N Engl J. 1992;327:1033.
Laparoscopic Adrenalectomy:
Retroperitoneal Approach
Marilou B. Fuentes and Cheah Wei Keat
Introduction advantage of direct approach without mobiliz-

ing adjacent structures justifying the shorter
With the advent of advances in radiologic imag- operative time and lower blood loss. The only
ing, there is an increase in the number of diag- drawback of this technique is the unfamiliar
nosed cases of Adrenal Incidentaloma (adrenal anatomic view of retroperitoneal space [5]. A
mass ≥ 1 cm diameter, discovered on imagining study on learning curve for retroperitoneoscopic
done for other organs). Prevalence of which is approach done by Barczynski and Walz showed
around 2% and noted to increase with age, that 20–25 cases should be done by an appren-
affecting 4% of middle-aged and increases to tice under the supervision of an experienced
10% in elderly patients. Tumor of the adrenal surgeon before being able to have a mean opera-
gland more than 4 cm in diameter or if the mass tive time of 90 min [6].
enlarges by 1 cm during observation period is
recommended to be surgically removed after
thorough endocrine clearance. The concept of Anatomy
minimally invasive surgery changed the
approach to adrenal tumors but did not changed Right adrenal gland is mostly suprarenal and
the indications and goals of treatment [1–4]. located in front of 12th rib, while the left is prer-
Posterior retroperitoneal adrenalectomy has the enally located in front of 11th and 12th ribs both
lateral edges of vertebral column.
Posteriorly, it is in close proximity to dia-
phragmatic crus and lateral arcuate ligament.
Anteriorly the right adrenal is lateral to inferior
M. B. Fuentes (*) vena cava and the left adrenal is with adjacent
Department of Surgery, The Medical City,
Pasig, Philippines organs such as spleen and the pancreatic tail.
Arterial supply: Superior adrenal artery from
Ateneo School of Medicine and Public Health,
Quezon City, Philippines inferior phrenic artery.
C. W. Keat
General Surgery, Ng Teng Fong General Hospital, • Middle adrenal artery from aorta
Singapore, Singapore • Inferior adrenal artery from renal artery
Division of General Surgery (Thyroid and Endocrine
Surgery), Department of Surgery, University Surgical Venous: each adrenal is usually drained by a
Cluster, National University Hospital, single adrenal vein, the importance of handling
Kent Ridge, Singapore this in tumors that secrete excess hormones.
https://doi.org/10.1007/978-981-19-3755-2_27
162 M. B. Fuentes and C. W. Keat
• Right vein is usually short (5–10 mm length) Indications

and drains to IVC (Fig. 1).
• Left vein is longer (about 30 mm in length) Oncological Recommendations
empties to left renal vein. • Over 30 HU by enhanced CT with tumor size
• Accessory veins in 5–10%. diameter of >4–5 cm and fast tumor growth
without local invasion [1].
Retroperitoneal Endoscopic Endocrinological Indications

Adrenalectomy • All cases of biochemically confirmed pheo-
chromocytoma; Cushing’s syndrome, primary
Retroperitoneoscopic approach was introduced hyperaldosteronism, and hyperandrogenic
by Martin Walz in mid-1990s as the more favor- syndrome [1].
able technique for adrenal tumors. The advantage
of less extensive dissection, and with bilateral
adrenalectomy done in same position, is gaining Contraindications
popularity since its introduction [7].
Advantages—does not need extensive mobili- 1. Large adrenal lesions (>8–10 cm).
zation, is not affected by previous abdominal sur- 2. Unstable comorbidities.
geries, same position for bilateral adrenalectomy, 3. Contraindications to anesthesia and
short surgery time. Tumors that are close to vena pneumoperitoneum.
cava, this approach offers a direct access therefore 4. Previous retroperitoneal surgery.
less manipulation of vena cava avoiding injury [8].
Disadvantages—difficult to learn because
there is a need for retroperitoneal view familiar- Preoperative Preparations
ity. This technique is not suitable for obese
patients and large tumor because of limited work- 1. Control of hypertension, correction of electro-
ing space. lyte abnormalities.
Fig. 1 Venous drainage

of the adrenal gland
Laparoscopic Adrenalectomy: Retroperitoneal Approach 163
(a) For pheochromocytoma, alpha blocker Surgical Technique

administration for 2–3 weeks preopera-
tively for heart rate normalization [1]. For Walz’s technique—patient on prone jackknife
potassium preparation, low sodium and position with bent hip joints at 90° angle to maxi-
high potassium diet with Spironolactone mally open the space between 12th rib and iliac
100–400 mg/daily for few weeks [4]. crest. Surgeon stands on the adrenal side to be
(b) If 1°aldosteronism is suspected, adrenal removed and the assistant on the opposite side.
venous sampling is routinely performed The first 1.5 cm incision is placed approximately
for lateralization and patient started on 1 cm inferior to the tip of 12th rib, followed by
spironolactone for at least 1 month preop- creation of retroperitoneal space by finger dissec-
erative. BP should be maintained below tion. Two additional incisions were made at the
150/100 mm Hg [2]. posterior axillary line and between the first trocar
2. Evaluation and optimization. site and mid-axillary line at the lower tip of 11th
3. Diagnostic criteria: Adrenal protocol CT, bio- rib [2].These two 5 mm ports are placed about a
chem marker screening for 1° aldosteronism, palm breadth apart from the first port to avoid
Cushing syndrome, and Phaeochromocytoma. being too close that may interfere with instru-
Screening laboratory tests: like ECG, chest x-ray, ment handling. CO2 insufflation can be set from
electrolytes, clotting parameters, and blood type. 12 mm Hg to a maximum of 25 mm Hg, depend-
ing on how to achieve the best exposure for the
adrenal gland [6, 9].
Instruments Exposure: The first step is visualization and
mobilization of the upper pole of the kidney.
• Two 12 mm port. Dissection is from superior pole from lateral to
• Maryland dissector. medial and inferior aspect of the adrenal.
• Harmonic scalpel.
• One 5 mm port.
• Clip applicator. For Right Adrenalectomy
• Suction/irrigation device.
• 30° scope. Investing fascia is opened transversely at the
• Curved scissors. upper pole until the IVC is identified and con-
• Specimen retrieval bag. tinues along the lateral edge to the right adre-
• Atraumatic graspers . nal vein which is usually located posterolateral
• Hook diathermy. to IVC. Once identified can be clipped and
may proceed to complete mobilization of the
Prone or semi-jackknife position with the hips gland. Early transection of feeding arteries
flexed (Fig. 2). between Gerota’s fascia and psoas muscle
results in tumor shrinkage and good bleeding
control [4, 9].
For Left Adrenalectomy
The Gerota’s fascia is opened at the superior

aspect of the kidney and dissection continued
medially along the renal vein until the adrenal
vein is identified, clipped with Hem-o-lock clips,
and divided. There is identifiable feeding arteries
Fig. 2 Patient and port positions which are often seen around renal pedicle and
164 M. B. Fuentes and C. W. Keat
just above posts muscle can be ligated with a ves- requiring steroid replacement are observed for
sel sealing system [4, 9]. 72–96 h prior to discharge [4]. Steroid replace-
Importance of early ligation of adrenal central ment is mandatory for patients post-surgery for
vein in Pheochromocytoma patients cannot be Cushing’s syndrome for several months until ade-
over-emphasized. This maneuver reduces the quate functioning of the remaining adrenal gland.
excessive catecholamine secretion thereby pre- Patients are allowed to ambulate, start on diet, and
venting intraoperative fluctuation of blood pres- require minimal analgesic [11]. Diagnostics such
sure [10]. as full blood count and electrolytes may be done
as clinically indicated. Periodic glucose monitor-
ing for Pheochromocytoma patients.
Indications for Conversion
• Uncontrolled hemorrhage. Practical Tips and Tricks [14]

• Cardiac arrhythmias.
• Complication rate—0–15% for unilateral,
Conversion rate was noted to be 2–14% [11], rises to 23% for bilateral.
Shen et al. reported that the significant indepen- • Male sex and high BMI correlate significantly
dent predictive factors for conversion to open with duration of OR.
were tumor size >5 cm, BMI of ≥24 kg/m2, and
Pheochromocytoma [12]. Position
• 90° angle between spine and legs should be
obtained to optimize distance between rib and
Complications iliac crest.
The most common intraoperative complications Trocar Position

are bleeding from adrenal and renal vein and • Correct and planned angle and position to
vena caval injuries while the postoperative com- avoid clashing of instruments and hand fatigue.
plications are retroperitoneal hematoma and If 11th rib is noted to be long, the trocar should
hyponatremia [11]. be adjusted to more cranial position to allow a
better degree of freedom for movement.
1. Neuromuscular pain—noted in 9% in one of
the largest series done by Walz et al. This is O2 Insufflation Pressure
C
secondary to subcostal injury during trocar • Can be increased to max of 25 mm Hg and can
insertion but is only temporary [13]. be adjusted according to the anatomy/working
2. Wound infection especially in patient’s with space of the patient. This helps to create good
Cushing’s syndrome. working space and in small vessel bleeding
tamponade; air embolism is a possibility but
none was reported even with the largest series
Postoperative Care of Walz et al. [8]
Hypotension is a possible problem postopera- Dissection

tively because of catecholamine decrease leading • Early identification of landmarks is crucial [8]
to vasodilatation reducing the cardiac output. It is best to start at the upper pole of the kid-
Cortisol, ACTH concentration, and serum electro- ney, conducted clockwise starting from 3 to 9
lyte are requested to assess if the patient will o’clock on the right and counterclockwise 9–3
require steroid coverage after surgery. Patients o’clock on the left.
Laparoscopic Adrenalectomy: Retroperitoneal Approach 165
Choice of Patient 7. Maccora D, Walls GV, et al. Bilateral adrenalec-

tomy: a review of 10 years’ experience. Ann R Coll
• for early part of surgical experience, do not go Surg Engl. 2017;99(2) https://doi.org/10.1308/
for tumors larger than 4 cm, should be smaller rcsann.2016.0266.
and avoid patients with BMI of >35 because 8. Ma J, Wang Y, et al. Outcome and safety of retroperi-
these patients have dense retroperitoneal fat toneoscopic and transperitoneal laparoscopic adre-
nalectomy: a comparative study of 178 adrenal tumor
adherent to capsule of the kidney, making dis- patients. Int J Clin Exp Med. 2018;11(9):9701–7.
section difficult. 9. Shiraishi K, Kitahara S, et al. Transperitoneal versus
retroperitoneal laparoscopic adrenalectomy for large
pheochromocytoma: comparative outcomes. Int J
Urol. 2018;26(2) https://doi.org/10.1111/iju.13838.
10. Ban EJ, Yap Z, et al. Hemodynamic stability during
References adrenalectomy for pheochromocytoma: a case control
study of posterior retroperitoneal vs lateral transperi-
1. Bednarczuk T, Bolanoswki M, et al. Adrenal inciden- toneal approaches. Medicine. 2020;99(7):e19104.
taloma in adults- management recommendations by https://doi.org/10.1097/MD.0000000000019104.
polish Society of Endocrinology. Endokrynol Pol. 11. Conzo G, Tartaglia E, et al. Minimally invasive
2016; https://doi.org/10.5603/EP.a2016.0039. approach for adrenal lesions: systematic review of lap-
2. Uludağ M, Aygün N, et al. Surgical indications aroscopic versus retroperitoneoscopic adrenalectomy
and techniques for adrenalectomy. Med Bull Sisli and assessment of risk factors for complications. Int
Etfal Hospital. 2020; https://doi.org/10.14744/ J Surg. 2016;28:S118–23. https://doi.org/10.1016/j.
SEMB.2019.05578. ijsu.2015.12.042.
3. Gagner M, Pomp A, et al. Laparoscopic adrenalec- 12. Hirano D, Hasegawa R, et al. Laparoscopic adrenalec-
tomy: lessons learned from 100 consecutive proce- tomy for adrenal tumors: a 21-year single-institution
dures. Ann Surg. 226(3):238–47. experience. Asian J Surg. 2014;38:79–84. https://doi.
4. Arezzo A, Bullano A, et al. Transperitoneal versus ret- org/10.1016/j.asjsur.2014.09.003.
roperitoneal laparoscopic adrenalectomy for adrenal 13. Walz A, et al. Posterior retroperitoneoscopic adre-
tumours in adults. Cochrane Database Syst Rev. 2018; nalectomy- 560 procedures in 520 patients. Surgery.
https://doi.org/10.1002/14651858.CD011668.pub2. 2006; https://doi.org/10.1016/j.surg.2006.07.039.
5. Vrielink OM, Wevers KP, et al. Laparoscopic 14. Alesina P. Retroperitoneal adrenalectomy - learning
anterior versus endoscopic posterior approach curve, practical tips and tricks, what limits its wider
for adrenalectomy:a shift to a new golden stan- uptake. Gland Surg. 2019;8 Suppl (1) S36-S40.
dard? Langenbeck's Arch Surg. 2017; https://doi. https://doi.org/10.21037/gs.2019.03.11
org/10.1007/s00423-016-1533-x.
6. Hisano M, Vicentini F, et al. Retroperitoneoscopic
adrenalectomy in pheochromocytoma. Clinics.
2012;67(51):161–7.
Part VI
Breast Surgery
Endoscopy-Assisted Breast
Surgery for Breast Cancer
Tang Siau Wei
Introduction than 5 cm for endoscopic-assisted total mas-

tectomy (EATM).
Modified radical mastectomy was traditionally • No evidence of multiple lymph node
the preferred method for treating operable breast metastasis.
cancer. With advances in surgical techniques over • No evidence of skin or chest wall invasion.
the past few decades, breast-conserving surgery
(BCS) and sentinel lymph node biopsy are now
acceptable treatments for early breast cancer. Over Contraindications [1, 3, 4]
the last two decades, endoscopic techniques had
initially been adapted to facilitate cosmetic breast • Multifocal/multicentric lesions (for EBCS).
augmentation surgery but are now increasingly • Inflammatory breast cancer.
adopted in the surgical management of breast can- • Paget’s disease of the nipple/nipple discharge.
cer [1–3]. It is often done to optimize the cosmetic • Breast cancer with nipple, pectoralis major/
outcome by performing surgery through small chest wall, or skin invasion.
wounds hidden in the axilla or periareolar areas. • Locally advanced breast cancer.
If endoscopic mastectomy is performed, it is often • Breast cancer with extensive axillary lymph
followed by immediate reconstruction. node metastasis (stage IIIB or later).
• Patients with severe comorbid conditions,
such as heart disease, renal failure, liver
Indications [1, 3, 4] dysfunction, and poor performance status as
assessed by the primary physicians.
• Early stage breast cancer (ductal carcinoma in
situ (DCIS), stage I or II).
• A tumor size less than 3 cm for endoscopic Pre-op Assessment
breast conserving surgery (EBCS) or no larger
• Thorough history and physical examination.
• Histopathologic confirmation of breast
T. S. Wei (*) cancer.
Division of General (Breast) Surgery, Department of
Surgery, National University Hospital, • Routine investigations as to hospital protocol
Singapore, Singapore for fitness to undergo general anesthesia.
Division of Surgical Oncology, National University • Breast imaging—Mammogram/Ultrasound/
Cancer Institute, Singapore, Singapore MRI (for EBCS) to delineate the extent of
e-mail: siau_wei_tang@nuhs.edu.sg disease.
https://doi.org/10.1007/978-981-19-3755-2_28
170 T. S. Wei
• Preoperative marking of inframammary fold,

extension of breast tissue at the lateral and
superior aspects performed with the patient in
an upright position.
• For nonpalpable lesions undergoing EBCS—
hookwire placement.
• EBCS—preoperative marking of resection
margins under ultrasound guidance with either
methylene blue or indocyanine green dye with
at least a 1 cm margin.
• Preoperative radiocolloid (99mTc) is injected to
aid in identification of the sentinel lymph node.
Fig. 1 Skin incisions
OT Setup
Instruments Required entinel Lymph Node Biopsy (SLNB)

S
• Lighted retractor (Vein harvest, Ultra • 2 cm transverse axillary incision is made close
Retractor, Vein Retractor). to the site of the hottest nodes that are detected
• 30 straight rigid 5 mm endoscope. using a hand-held gamma probe.
• Bipolar scissors/electrocautery or Energy • The axillary tissue is dissected to identify any
device (e.g., Harmonic scalpel). blue ducts, which is traced to identify the sen-
• Wound protector. tinel lymph node.
• OptiView port. • SLNB is then confirmed with the hand-held
• Endocatch retrieval bag. gamma probe and sent for intraoperative fro-
zen section.
Patient Position • If the frozen section results show malignancy
• The patient is in supine position. in the sentinel lymph node, axillary dissection
• Both arms are abducted to 90°. is performed through the same incision after
• Endoscopic video monitors are positioned on completion of the breast surgery.
the opposite side of the patient.
• 5 ml of diluted 0.5% Patent blue dye is injected Posterior Dissection
into the upper outer quadrant of the periareo- • After completing the SLNB, the dissection is
lar after induction of anesthesia for sentinel carried out to the lateral border of the pectora-
lymph node biopsy. lis major muscle.
• Dissection in the retromammary space,
between the pectoralis muscle fascia and pos-
Surgical Technique [1, 4–8] terior breast parenchyma is carried out using a
retractor with an optical system (endoscopic
Incisions vein harvest, Ultra retractor, Vein Retractor)
• 2 cm axillary incision (A). with blunt dissection (Fig. 2).
• Semicircular Periareolar incision (less than • The surrounding tissue is pulled up using the
half of circumference of areolar) (B). endoscopic retractor and a suction tube to cre-
• If required, additional 5 mm incisions are ate sufficient working space and to evacuate
placed at the lateral breast and/or at inframam- mist and smoke.
mary fold for trocars to assist in dissection • The penetrating vessels are coagulated and cut
(C/D) (Fig. 1). with bipolar scissors, harmonic scalpel, or
Endoscopy-Assisted Breast Surgery for Breast Cancer 171
Fig. 2 Retromammary space dissection
electrocautery to ensure a clear visual field

and uncomplicated hemostasis.
• Alternatively, the retromammary space could
be dissected using a pre-peritoneal dissection
balloon or carbon dioxide insufflation.
• For mastectomy, the dissection is carried out
throughout the whole retromammary space to
the anatomic margins of the breast.
• For EBCS, dissection is performed to cover an
area further beyond the tumor margins
(marked preoperatively) to facilitate tissue
mobilization for closure of the defect [9].
ubcutaneous Skin Flap Development

S
• A semicircular periareolar incision is made.
An appropriately sized wound protector is Fig. 3 Saline injection
placed into the incision to protect the periareo-
lar wound and ensure adequate visualization.
• The retroareolar tissue is dissected and the
nipple base tissue is sampled and examined by
intraoperative frozen section.
• If the frozen section is positive for malignancy,
the whole nipple areolar complex is removed.
• A combination of normal saline, lignocaine
0.05%, and epinephrine 1:1000000 as a
tumescent solution is infiltrated subcutane-
ously into the breast to facilitate dissection
Fig. 4 Subcutaneous tunneling method
and minimize bleeding (Fig. 3).
• A 5 mm thick skin flap is created using the
optical bladeless trocar (Xcel port) using the cautery, and/or energy devices (e.g., harmonic
“subcutaneous tunnelling method,” whereby scalpel).
the trocar is used to separate the breast paren- • For mastectomy, the dissection is carried out
chyma from the overlying skin and subcutane- throughout the whole anterior surface of the
ous tissue under direct endoscopic visualization breast to the anatomic margins of the breast
(Fig. 4). (Fig. 5).
• The “septa” created between the tunnels are • For EBCS, dissection is performed to cover an
then dissected using bipolar scissors, electro- area further beyond the tumor margins
172 T. S. Wei
• The surgical specimen can then be removed

through the axillary incision or periareolar
incision (with or without an endocatch).
• For mastectomy, immediate reconstruction
can then be performed using implants or
autologous tissue, and a drain may be placed
in the surgical cavity [10].
• For EBCS, surgical clips are placed in the cav-
ity and the breast tissue is then mobilized to
close the defect, with or without oncoplastic
techniques [9].
Postoperative Care
• Similar to open surgery, would depend on

reconstructive technique (if any).
Fig. 5 Dissection along the anterior surface of the breast
• Standard analgesia as required.
• Regular diet as tolerated.
• Discharge the patients when comfortable and
able to drink, eat, and walk.
Complications and Management [1, 8]
• The complications reported with endoscopic

breast surgery are generally similar to that of
open surgery—e.g., Seroma, superficial or
deep skin burns, ecchymoses, infection; and
can be managed in a similar manner.
• If insufflation is used to develop the surgical
planes, the patient may have subcutaneous
Fig. 6 Dissection beyond tumor margins emphysema in the breast and surrounding tis-
sues postoperatively. This is usually self-
(marked preoperatively) to facilitate tissue limiting and will resolve spontaneously.
mobilization for closure of the defect [9] • For EBCS, the patient may develop fat necro-
(Fig. 6). sis if there are wide areas of tissue mobiliza-
tion for resection and reconstruction.
pecimen Excision and Reconstruction
S
• For mastectomy, the anterior subcutaneous
dissection will meet the posterior retromam-
mary space dissection at the anatomic margins References
of the breast to complete the mastectomy.
• For EBCS, the breast tissue is then divided 1. Mok CW, Lai HW. Endoscopic-assisted surgery in the
management of breast cancer: 20 years review of trend,
according to the preoperative markings using techniques and outcomes. Breast. 2019;46:144–56.
bipolar scissors, energy devices, or electro- 2. Sakamoto N, Fukuma E, Higa K, Ozaki S, Sakamoto
cautery with the help of the endoscopic light M, Abe S, Kurihara T, Tozaki M. Early results of an
retractor completing the lumpectomy [9]. endoscopic nipple-sparing mastectomy for breast can-
cer. Ann Surg Oncol. 2009;16:3406–13.
Endoscopy-Assisted Breast Surgery for Breast Cancer 173
3. Tamaki Y, Nakano Y, Sekimoto M. Transaxillary 7. Kitamura K, Ishida M, Inoue H, Kinoshita J,

endoscopic partial mastectomy for comparatively Hashizume M, Sugimachi K. Early results of an
early-stage breast cancer: an early experience. Surg endoscope assisted subcutaneous mastectomy
Laparosc Endosc. 1998;8:308–12. and reconstruction for breast cancer. Surgery.
4. Lai H-W, Chen S-T, Chen D-R, Chen S-L, Chang 2002;131(1):S324–9.
T-W, Kuo S-J, et al. Current trends in and indications 8. Soybir G, Fukuma E. Endoscopy assisted onco-
for endoscopy-assisted breast surgery for breast can- plastic breast surgery (EAOBS). J Breast Health.
cer: results from a six-year study conducted by the 2015;11:52–8.
Taiwan endoscopic breast surgery cooperative group. 9. Lee E-K, Kook S-H, Park Y-L. Endoscopy-assisted
PLoS One. 2016;11(3):e0150310. breast-conserving surgery for early breast cancer.
5. Du J, Liang Q, Qi X, Ming J, Liu J, Zhong L, Fan World J Surg. 2006;30:957–64.
L, Jiang J. Endoscopic nipple sparing mastectomy 10. Lai HW, Wu HS, Chuang KL, Chen DR, Chang TW,
with immediate implant-based reconstruction versus Kuo SJ, Chen ST, Kuo YL. Endoscopy-assisted total
breast conserving surgery: a long-term study. Sci Rep. mastectomy followed by immediate pedicled trans-
2015;7:45636. verse rectus abdominis musculocutaneous (TRAM)
6. Ho WS, Ying SY, Chan ACW. Endoscopic-assisted flap reconstruction: preliminary results of 48 patients.
subcutaneous mastectomy and axillary dissection Surg Innov. 2015;2(4):382–9.
with immediate mammary prosthesis reconstruction
for early breast cancer. Surg Endosc. 2002;16:302–6.
Laparoscopic Omental Flap Partial
Breast Reconstruction
Siau Wei Tang
Introduction from oncologic resections or trauma [1].

However, the morbidity associated with a lapa-
Oncoplastic breast surgery combines oncological rotomy to harvest the flap has limited its use.
resection of a breast malignancy with plastic sur- With advances in endoscopic surgery, laparo-
gical techniques for immediate reconstruction of scopic harvesting of the omental flap has made it
the defect using volume replacement or volume a viable option in breast reconstruction surgery
displacement techniques. As breast-conserving [2–4], particularly for defects in the upper and
surgery increases in popularity, partial breast lower inner quadrant of the breast, with minimal
reconstruction using volume replacement tech- donor site morbidity.
niques has evolved to allow excision of larger
tumors while minimizing cosmetic deformity.
Lateral chest wall perforator flaps (thoracodorsal Indications
artery perforator (TDAP) flap and the lateral
intercostal artery perforator (LICAP) flap) are • Breast conserving surgery where 20–50% of
commonly used for tumors in the outer half of the the breast volume is resected.
breast; superior epigastric artery perforator • Tumor location in the upper inner quadrant,
(SEAP) flaps are commonly used for lower inner lower inner quadrant, or lower outer quadrant
quadrant tumors. Upper inner quadrant defects of the breast.
present a challenge for volume replacement in
partial breast reconstruction as there are limited
options for local flaps and would require ade- Contraindications
quate mobilization for a longer pedicle if perfora-
tor flaps are utilized. • If a large amount of skin over the tumor is
Historically, the omental flap has been used to resected, omental flap is not a suitable recon-
reconstruct chest and upper abdominal wounds structive option.
• Extensive disease involving more than 50% of
the breast (as it is difficult to estimate the
S. W. Tang (*) omental volume preoperatively and may have
Division of General (Breast) Surgery, Department of
Surgery, National University Hospital, inadequate volume for replacement).
Singapore, Singapore • Tumor location in the upper outer quadrant.
Division of Surgical Oncology, National University • Patients with previous upper midline laparot-
Cancer Institute, Singapore, Singapore omy/peritonitis/intra-abdominal malignancy.
e-mail: siau_wei_tang@nuhs.edu.sg • Morbid obesity (BMI >35).
https://doi.org/10.1007/978-981-19-3755-2_29
176 S. W. Tang
Pre-op Assessment Patient Position
• Histopathologic confirmation of breast • The patient is in supine position or split legs

cancer. (French) position.
• Routine investigations as to hospital protocol • Both arms are abducted to 90°.
for fitness to undergo general anesthesia. • Endoscopic video monitors are positioned
• Breast imaging—Mammogram/Ultrasound/ next to the patient’s head on the patient’s left.
MRI (for EBCS) to delineate the extent of • Surgeon to stand on the right of the patient or
disease. between the patient’s legs (French position).
• The volume of omentum is often unpredict- • The assistant is standing on the patient’s left.
able and is difficult to estimate with current
imaging modalities. Some surgeons may opt
to do a separate diagnostic laparoscopy to esti- Surgical Technique [4–7]
mate the omental volume (particularly if con-
sidering reconstruction of >50% of the breast) • Wide local excision of the tumor is performed
and to evaluate for any adhesions/intra- by the breast surgeon, ideally through an
abdominal pathology prior to the oncoplastic incision at the medial end of the inframam-
surgery. mary fold (IMF).
• Pre-op marking of the inframammary fold and
midline on the sternum is performed in the
standing position. Incisions
• The distance between the IMF and the costal
margin is assessed in the supine position. • 12 mm camera port is inserted at the umbili-
• The breast tumor and resection margins are cus using the open technique.
outlined on the skin of the breast. • Two 5 mm working ports are inserted at the
• Preoperative placement of hook wire is right midclavicular line, at the right upper
required if the tumor is nonpalpable. quadrant and right lower quadrant.
• Prophylactic antibiotics are given at induction • 5 mm assistant port is inserted at the left lower
of anesthesia. quadrant midclavicular line.
• Additional 5 mm assistant port may be inserted
in the left upper quadrant midclavicular line
OT Setup (if required).
• Two separate teams can operate on the breast

and abdomen concurrently Laparoscopic Harvesting
of the Omental Flap
Instruments Required • After a 30°laparoscope is inserted through the

umbilical port, pneumoperitoneum is main-
• Veress needle (Optional). tained at 10 mmHg and the three other 5 mm
• 30° telescope 10 mm and 5 mm trocars are inserted under direct vision.
• Atraumatic graspers 5 mm. • Diagnostic laparoscopy is performed, where
• Energy device (e.g., Harmonic scalpel). the omentum is evaluated for size and
• Curved Maryland dissector 5 mm. adhesion.
• Suction/irrigation device. • The omentum is moved toward the upper
• Wound protector. abdomen and the lesser sac is entered.
Laparoscopic Omental Flap Partial Breast Reconstruction 177
• The omentum is dissected from the left side of Partial Breast Reconstruction
the transverse colon toward the splenic flexure
using an energy device (e.g., Harmonic scal- • The IMF incision used to perform the wide
pel). It is transected toward the lower pole of local excision is used to exteriorize the omen-
the spleen, and the left gastroepiploic vessels tal flap.
are divided (Fig. 1). • A subcutaneous tunnel is created from the
• The omentum is then dissected from the stom- medial side of the IMF incision toward the
ach toward the greater curvature, with care xiphoid process, over the anterior sheath of
taken to preserve the right gastroepiploic ves- the rectus muscle. Subcutaneous fat around
sels as the main pedicle. the tunnel is resected to avoid a bulge from the
• The dissection is then continued to dissect pedicle (after it has been exteriorized).
the omentum from the right transverse colon • A 3 cm longitudinal incision is made in the
and the duodenum and pylorus, where the linea alba (just below the xiphoid process) to
fusion between the posterior leaf of the gas- enter the abdominal cavity.
trocolic ligament and the anterior leaf of the • The pedicled omental flap is carefully exteri-
transverse mesocolon is carefully divided orized through this tunnel, with care taken to
toward the anterior capsule of the pancreas avoid torsion or kinking of the pedicle.
head. • The linea alba incision may need to be wid-
• Fatty tissue at the root of the right gastroepi- ened to allow the omental flap to be exterior-
ploic artery and vein are resected to enable a ized. If so, it must be partially closed again
long and narrow pedicle of the flap to mini- after, to minimize the risk of ventral hernia in
mize the risk of a subsequent ventral hernia, the future.
completing the dissection of the omental • When exteriorized, hemostasis of the omental
flap. flap is performed, and vascularity of the flap is
reassessed (Fig. 2).
• The size of the omental flap is then assessed in
relation to the size of the defect in the breast.
Fig. 1 Steps for laparoscopic dissection of the omentum Fig. 2 Assessment of vascularity of omental flap
178 S. W. Tang
Fig. 3 Assessment of omental flap in relation to breast Fig. 4 Skin closure by layers
size defect
• Discharge the patient when she is comfortable

If it is too large, the periphery of the omentum and able to drink, eat, and walk.
is trimmed (Fig. 3).
• Pneumoperitoneum should then be reinstated,
and laparoscopy performed to check for any Complications
tension in the pedicle. High tension in the ped-
icle will cause traction on the distal stomach, • Vascular injury—if inadvertent injury is made
which may lead to gastric outlet obstruction. to the pedicle, the omentum may no longer be
• The appropriately sized omental flap is then viable and alternative reconstructive methods
tucked into the breast defect to fill the cavity. should be considered (e.g., Latissimus dorsi
If there was an extensive subcutaneous or pre- flap).
pectoral dissection of the breast tissue around • Bleeding/hematoma.
the defect, the edges of the residual breast tis- • Seroma.
sue should first be fixed onto the pectoralis • Infection.
major muscle in its original position, to avoid • Bowel injury (small/large bowel injury).
movement of the omental flap. • Skin flap necrosis.
• Fixation of the omental flap to the chest wall is • Graft fat necrosis.
usually not necessary. A closed suction drain • Late complication—ventral hernia, intra-
may be placed in the breast cavity. abdominal adhesions.
• The skin wound is then closed in layers, recre-
ating the IMF (Fig. 4).
References
Postoperative Care 1. Claro F Jr, Sarian LO, Pinto-Neto AM. Omentum for
mammary disorders: a 30-year systematic review. Ann
Surg Oncol. 2015;22:2540.
• Standard analgesia as required. 2. Cothier-Savey I, Tamtawi B, Dohnt F, Raulo Y, Baruch
• Regular diet as tolerated. J. Immediate breast reconstruction using laparoscopi-
• If close suction drain is used in the breast cav- cally harvested omental flap. Plast Reconstr Surg.
2001;107:1156–63.
ity, it can be removed when the average drain-
age over 24 h is <50mls.
Laparoscopic Omental Flap Partial Breast Reconstruction 179
3. Góes JCS, Macedo ALV. Immediate reconstruction Techniques in oncoplastic surgery. 2nd ed; 2017.
after skin-sparing mastectomy using the omental flap p. 369–86.
and synthetic mesh. In: Spear S, editor. Surgery of the 6. Zaha H, Inamine S. Laparoscopically harvested
breast: principles of the art. 2nd ed. Philadelphia, PA: omental flap: results for 96 patients. Surg Endosc.
Lippincott; 2006. p. 786–93. 2010;24(1):103–7.
4. Zaha H, Inamine S, Naito T, Nomura 7. Zaha H, Sunagawa H, Kawakami K, et al. Partial
H. Laparoscopically harvested omental flap for breast reconstruction for an inferomedial breast
immediate breast reconstruction. Am J Surg. carcinoma using an omental flap. World J Surg.
2006;192:556–8. 2010;34(8):1782–7.
5. Zaha H. Omental flap reconstruction; in partial breast
reconstruction. In: Losken A, Hamdi M, editors.
Part VII
Video Assisted Thoracic Surgery
Basic Principles and Advanced
VATS Procedures
Narendra Agarwal and Bharti Kukreja
Introduction Jacobaeus introduced thoracoscopic examination

and use of thoracoscope for releasing pleural adhe-
In the era of growing enthusiasm for minimally sions [3]. Further research and development of
invasive surgical approaches, many general and microcameras in the 1980s led to the arrival of
thoracic surgeons have fostered a resurgence of Video-assisted thoracoscopic surgery in 1990s [4].
interest in thoracoscopy. Over the last two decades, VATS has since been used and different modi-
surgeons have expanded the use of thoracoscopic fications for the same are being done all over the
or video-assisted thoracic surgery (VATS), proce- world from VATS under GA, to awake VATS [5];
dures to address a variety of thoracic pathologies from three ports to single port surgery (uniportal)
classically managed through open thoracotomy. [6]; further developments are anticipated.
The goal of this chapter is to guide minimal inva-
sive surgeons who are trained in open thoracic pro-
cedures, and thoracic surgeons beginning their Basic Principles of VATS
thoracoscopic experience with the basic operative
setup for thoracoscopic (VATS) surgery. The primary operative strategy is to orient the
thoracoscopic instruments and the camera in tri-
angulation, so that all are being used in the same
Historical Background general direction facing toward the target pathol-
ogy [7] (Fig. 1).
The evolution of VATS can be traced back to the To accomplish the basic maneuvers of thora-
early nineteenth century when Bozzini used an coscopy and to conduct effective VATS opera-
endoscope to examine the urinary bladder (cystos- tions, several basic principles should be applied.
copy) [1]. Driving in the same direction, a couple
of years later Carson induced artificial pneumo- 1. The trocar sites and thoracoscope should be
thorax for the treatment of pulmonary Kochs [2]. placed keeping the target pathology and fol-
Almost a decade later, in the early 1900s, lowing in mind.
• Ability to achieve a panoramic view and

N. Agarwal (*) provide room to manipulate the tissue.
Department of Thoracic Surgery, Fortis Memorial • Strategic positioning of the thoracoscopic
Research Institute, Gurgaon, India camera and the endoscopic instruments is
B. Kukreja vital to the success and efficiency of the
Medanta the Medicity, Gurgaon, India procedure.
https://doi.org/10.1007/978-981-19-3755-2_30
184 N. Agarwal and B. Kukreja
Working Space
Collapsed Lung
Single lung
ventilation
Fig. 2 Doube lumen single lung ventilation
The indications for double lumen tube intuba-

tions mainly are:
• To prevent cross-contamination of a nonin-

volved lung from blood or pus.
• To control the distribution of ventilation in
cases where there is a major air leak—such as
Broncho pleural fistula, tracheobronchial
Fig. 1 Baseball diamond: Principle for port placement trauma, or in major airway surgery.
• To perform Broncho pulmonary lavage.
• Pneumonectomy.
• Avoid instrument crowding, which may • Lobectomy.
otherwise result in “fencing” during instru- • Thoracic aneurysm repair.
ment manipulation.
• Avoid mirror imaging by positioning Use of a single lumen tube is done in procedures
instruments and thoracoscope (approach like esophagectomy or mobilization of esophagus,
the lesion in the same general direction thymectomy, thoracic spine access, sympathec-
with instruments and camera). tomy, and diagnostic procedures using insufflation
of carbon dioxide into the thorax at the beginning
2. To avoid operative chaos, move or manipulate of the procedure to facilitate a more complete and
instruments or the camera one by one, rather expeditious collapse of the lung. In such cases, the
than randomly or synchronously. intrapleural pressure is measured and kept lower
3. Instruments should be manipulated only when than 10 mm Hg to avoid mediastinal tension and
seen directly through the thoracoscope. hemodynamic compromise. It is necessary to use
4. All instruments should have a long working air-tight valves (reusable or disposable) trocars to
length to avoid operative struggle. seal the gas within the thorax when this carbon
dioxide insufflation technique is used.
Anesthesia
Preoperative Work Up
Anesthesia used most commonly is General
anesthesia along with single lung ventilation The role of the preoperative evaluation is to
using Double lumen endotracheal tube or bron- determine the risk and morbidity associated with
chial blocker (Fig. 2). the proposed procedure. The assessment should
Basic Principles and Advanced VATS Procedures 185
focus on pulmonary and cardiac conditions, as Lung

these represent the most common complications • Lung cancer.
after thoracic surgery. • Bronchiectasis.
Cardiac Risk Assessment: The American • Aspergilloma and other fungal infections.
Heart Association recommends noninvasive test- • Hydatid cyst in the lung.
ing as a minimum for such patients, with addi- • Emphysema.
tional invasive testing and intervention as • Destroyed lung: tuberculosis.
indicated. • Complications of Tuberculosis.
• Spontaneous pneumothorax.
• History of a cardiac condition prior to myo-
cardial infarction, congestive heart failure, Pleura
diabetes, and cerebrovascular disease and car- • Undiagnosed/complex/recurrent effusion.
diac medications. • Empyema.
• Unable to climb more than two flights of • Pericardial effusion.
stairs. • Diagnostic biopsy.
• Pleurodesis and pleurectomy.
Pulmonary function test: Adequate pulmonary
reserve is assessed through the use of pulmonary Mediastinum
function testing, with occasional use of perfusion • Mediastinal mass.
scanning and exercise testing when appropriate. • Disease of thymus.
This algorithm evaluates pulmonary function • Parathyroid adenoma excision.
in three areas:
Esophagus
• Respiratory mechanics (forced expiratory vol- • Benign esophageal tumors.
ume in 1 s [FEV1]). • Esophageal cancer.
• Parenchymal function (diffusing capacity for • Esophageal diverticula.
carbon monoxide [DLCO]).
• Cardiopulmonary interaction (Vo2max). Diaphragm
• Laboratory studies: Standard blood work • Eventeration.
should include: • Hernia.
• Complete blood count.
• Electrolyte panel. horacic duct ligation
T
• Clotting parameters. Sympathectomy.
• Liver function tests.
• Preoperative imaging studies: they help to
confirm the planned extent of resection and Positioning
the suitability of a VATS approach.
• Contrast-enhanced computed tomography The patient is positioned in lateral decubitus
(CT). position (Fig. 3) with the thorax surgically pre-
• Positron emission tomography (PET) in suspi- pared in case conversion to an open thoracot-
cious malignancy or malignant cases. omy is necessary during the course of the
operation. This is accompanied by flexion of the
operating table at the level of the tip of the scap-
Indications ula to widen the intercostal space [8–11]. The
flexion is achieved either by putting a bolster or
Indications are as below according to organ/tis- flexing the operating table, with the operative
sue involved: lung facing up and nonoperative lung in the
dependent position. The lateral decubitus posi-
Fig. 3 Position of VATS: Lateral deubitus

4
B
tion provides adequate access to most thoracic 5

structures which include the lungs, pleura, Working Port C
Assistant / 6
esophagus, and pericardium among other medi-
Retraction Port
astinal structures. Care must be taken at all 7 A
Camera Port
times to avoid nerve injury by adequately pad-
8
ding pressure points The patient’s shoulder and
arm are extended and secured to a side rest.
Port Placement
Using sterile techniques, the port site is created

by making incisions in the intercostal space.
The incisions are parallel to the long axis of the
intercostal space. The surgeon must take care
that these incisions are in the center of the Fig. 4 VATS: Port placement
space to avoid injury to the intercostal nerves
that run in a groove at the lower border of the There are many different port placements in
ribs. Then using a hemostat bluntly spread the VATS being used throughout the world. The ear-
fascia and muscle layers until the pleural cav- liest established was referred to as “baseball
ity is entered. diamond” which consist of 10–12 mm incisions
The first port incision should be at the maxi- with the placement varying from surgeon to sur-
mum distance from the target site of dissection geon according to their preferred approach for
or inspection to allow better visualization. the particular patients. Multiple different varia-
Mostly the choice of incision is at the seventh tions of the above have been seen now including
or eighth intercostal space at the anterior to the two port and even single port technique.
midaxillary line. This incision is best suited for With two port technique using an anterior and
the placement of chest tube at the end of the an inferior port, and single port technique using
procedure. Surgical interventions are made the camera and multiple instruments through the
over the rib to prevent any injury to the neuro- same port.
vascular bundle.
The second incision site is the anterior fourth
and fifth intercostal space between the midcla- Instruments
vicular and anterior axillary line.
The third incision is posterior, at the fifth and The instruments generally used in VATS have
sixth intercostal space adjacent to the scapula salient features like long working length which
(Fig. 4). provides the familiarity of traditional handles for
Fig. 5 VATS: Short trocars
Fig. 6a VATS Instrument: Thin Shaft and Curved shape

Instruments
secure manipulation and superior tactile response.
The Sliding Shafts enable the instrument to be
fully functional when placed through a port or
very small incision and also minimize Patient
Trauma. Continuous technical advancements in
vats instrumentation have happened in the last
decade.
Commonly used instruments during VATS Fig. 6b Decortication Forcep
procedure are:
• Short trocars (Fig. 5). The OR Setup

• 30/45 telescope
• Usual range of 5 mm thoracic/endoscopic The operating room should be fully equipped that
instruments (grasping forceps, decortication allows the surgeon at any immediate potential to
ring forceps (Fig. 6b), DeBakey forceps, small convert to open thoracotomy. Video-assisted tho-
and large dissectors, scissors, suction) racic surgery (VATS) requires a high definition
(Fig. 6a). (HD) video monitor, together with VATS instru-
• 5 mm bipolar shears. ments allowing the surgeon to view a sharp,
• 5 mm vessel sealing device. high-
resolution image within the chest cavity.
• 5 mm endo peanuts. The organization of the operation room is done
• 10 mm clip applier. based on the surgeon’s surgical approach.
• Endo-stapler, preferably with curved tip. There are two types of approaches:
• Large retrieval bag.
• Conventional open thoracic instrumentation • Anterior (Fig. 7a).
ready on a separate table. • Posterior (Fig. 7b).
Fig. 7a Anterior
appoach: Video-assisted Wall Mounted
Wall Mounted Monitor 2
thoracic surgery Monitor 1
Anesthetsiologist
Surgeon
Monitor
Scrub Nurse
Assisting
Surgeon
Light Source
Video Process
Diathermy
Suction
Anesthetsiologist
Fig. 7b Posterior Wall Mounted
Wall Mounted Anesthetic Monitor 2
approcah: Video-assisted Monitor 1
Machine
thoracoscopic surgery
Assisting
Surgeon
Monitor
Scrub Nurse
Surgeon
Anesthesia
General anesthesia, along with single lung intu-

bation [13], a bilateral two port VATS approach is
performed.
Technique
• The sterile field includes the neck, both axillae

and upper arms down to the costal margin
bilaterally.
• At fourth or fifth intercostal space with an
anterior axillary line, approximately 1 cm
Fig. 8 Anatomical landmark for port placement in incisions are made for camera port (Fig. 8).
sympathectomy
• Insufflation of carbon dioxide for active lung
collapse using intra pleural Pressure up to
VATS Sympathectomy 8 mmHg.
• The zero-degree thoracoscope is introduced
It is a surgical procedure in which a portion of through the port.
the sympathetic nerve trunk in the thoracic • The thoracic chain is readily identified and
region is destroyed [1, 2]. The most common covered by the thin layer of the parietal pleura.
area targeted in sympathectomy is the upper • A diathermy hook is inserted through the
thoracic region, that part of the sympathetic third midclavicular line intercostal space
chain lying between the first and fifth thoracic (Fig. 8).
vertebra (Fig. 8). • The sympathetic chain is visualized behind
the parietal pleura, which is then scored on
either side using the cautery to delineate the
Indications position of the chain and the extent of the
planned cauterization which corresponds to
• Hyperhidrosis [12]. the extent of the chain destroyed.
• Splanchnic pain. • Using the ribs as reference, the sympathetic
• Reflex sympathetic dystrophy (RSD). chain is then cauterized and divided from T2
• Upper extremity ischemia is also appropriate to T3 for patients with predominantly palmar
when nonsurgical treatment fails. hyperhidrosis and from T2 to T4 for patients
• Prolonged QT interval. with predominantly axillary hyperhidrosis
[14]. Possible anatomical variations such as
the Kuntz nerve, a transverse dissection along
Position the rib is performed (Fig. 9).
• The thoracoscope is then removed and
The patient is positioned supine with both arms replaced with a small red rubber catheter. With
outstretched on arm boards and the trunk in a 30° positive pressure ventilation, the catheter is
Fowler position. The position helps the apex of then removed under suction to allow expan-
the lung to fall apart. sion of the lung.
• Pneumothorax.
• Recurrence.
Vats Wedge Resection
It is a minimally invasive technique for nonana-

tomical limited resection of a lung. It is preferred
over open as it is muscle sparing non-rib spread-
CAMERA IMAGE ing and does not involve thoracotomy [15]. It is
better suited for peripherally located lesions
ILLUSTRATION
compared to deep-seated central pathology which
2nd rib
Subclavian
vessels
is very arduous and difficult to secure sufficient
Intercostal Sympathetic surgical margin [16] (Fig. 10). To attempt such
neurovascular chain/ganglia
bundle deep-seated resections can cause prolonged air
leak and delayed recovery. Lesions at the periph-
3rd rib SVC
ery or outer one-third of the lung are considered
the most suitable indications for wedge
resections.
4th rib Azygos vein
Indications
It has both diagnostic and therapeutic roles.

Fig. 9 Thoracic sympathetic chain
Therapeutic
• The skin incision is closed with a single
absorbable 3–0 suture followed by the place- • Early-stage (NSCLC; T1N0M0) and early-
ment of skin types. stage in patients with limited cardiopulmonary
• Contralateral sympathectomy is performed in reserve (although lobectomy is preferred).
a similar manner without changing the patient’s
position.
Postoperative
• No chest tubes are routinely placed at the end

of the procedures.
• All resected sympathetic chain specimens are
sent for histopathology.
• Patients are generally discharged the same day.
Complications
• Compensatory sweating.
• Horner’s syndrome. Fig. 10 High-resolution computed tomography of soli-
• Bleeding. tary lung lesion
• Metastasectomy for pulmonary metastases

due to renal, breast, colon malignancy, mela-
noma, sarcoma.
• Ground-glass opacification lesions on chest
CT scan in patients with past or present cancer
[16].
• Localization and excisional biopsy of ill-
defined or small pulmonary lesions [17]
• Resection of hamartoma.
• Resection of pulmonary sclerosing
hemangioma.
• Resection of intralobar sequestrated lung.
• Resection of localized peripheral
bronchiectasis.
• Lung volume reduction surgery in end-stage
emphysema.
• Resection of pulmonary arteriovenous malfor-
mation (PAVMs) [18, 19].
Fig. 11 Wedge resection
• Infectious tubercular granulomas, aspergil-
loma, and focal organizing pneumonia.
• Since there are limitations of finger palpation
of the target site other techniques used to iden-
Diagnostics tify target site are preoperative CT-guided
needle placement, hook-wire localization, or
• Excision biopsy of solitary/pulmonary nodules. placement of radio-opaque dye (methylene
• Excisional biopsy of ill-defined or small pul- blue). These can be used for guidance and
monary lesions [17]. lesion detection intraoperatively with
• Interstitial lung disease (ILD), wedge resec- fluoroscopy.
tions for diagnostic purposes, the lingula or • After localization resection is done by using
the middle lobe are usually preferred, although endostaplers, larger lesions require planning
alternative segments may be selected. with numerous staple runs. The deflated lung
• Pulmonary fibrosis. tissue can be rotated from the apex or base to
• Resection of ruptured/bullous lung. lie over hilum to allow alignment for straight
• Resection of pulmonary sclerosing staple cuts.
hemangioma. • Tissue is delivered using endo bag from the
anterior working port.
• Before closing the ports lung is inspected for
Surgical Technique any air leaks.
• Chest tube with underwater seal is placed
• In lateral decubitus and ports, placement are from inferior port and lung is allowed to
done as described above. expand completely.
• Localization of the pathologic site is done
based on visceral pleural changes such as
puckering, dimpling, raised lesions over a Postoperative
deflated lung, increased vascularity, or overly-
ing pleural adhesions (Fig. 11). • Postoperative pain management consists of
• Gentle handling of the lung parenchyma to narcotics and/or NSAIDS.
avoid unnecessary air leak or bleeding due to • Chest physiotherapy and early ambulation are
tear. recommended.
• Chest tube is removed when the pleural effu- [23] in asymptomatic patients whereas some
sion is lower than 200 mL/day and air leak prefer to wait for the occurrence of symptoms
flow <40 mL/min for more than 8 h (and before surgery to avoid the risk of complica-
without spikes of airflow greater than this
tions in otherwise clinically asymptomatic
value) [20]. patients [24].
Complications Preoperative
• Wound infection. CT should be done to record the progress, size of

• Persistent air leak. bulla or bullae, identify the proper anatomy of the
• Subcutaneous emphysema. bulla as well as its surrounding tissue, and there-
• Hemothorax. fore help the surgeon to plan the procedure
• Pneumonia. (Fig. 12).
• Atelectasis.
• Broncho pleural fistula.
• Local and port-site recurrence of malignancy Anesthesia
[8] (more common with wedge resection than
with lobectomy). Single lung ventilation by use of a double-lumen
endotracheal tube or bronchial blocker. Placement
of a thoracic epidural catheter for postoperative
VATS Bullectomy and Pleurodesis pain control.
VATS bullectomy is a minimally invasive surgery

to remove bulla, i.e., dilated air space or air-filled Procedure
pockets from the lung parenchyma (Fig. 10).
Pleurodesis is the procedure of sticking together • The first step in the surgery is the placement of
the coverings of the visceral and the parietal the ports in the lateral decubitus position
pleura of the lung together. described above. The first incision should be
VATS bullectomy and pleurodesis together taken very carefully after accessing the com-
have been seen in various studies to improve the puted tomography imaging as the lungs might
outcomes in patients with spontaneous/recurrent be adhered to the chest wall. Adhesiolysis lead
pneumothorax or emphysema [21, 22].
Indications
• In asymptomatic cases: Large bullae occupying

more than 30% of lung volume (with underly-
ing lung comparatively nonemphysematous).
• Symptomatic cases: after ruling out other
causes of dyspnoea.
• When patient presents with complications due
to ruptured bulla such as pneumothorax, infec-
tion, chest pain, or hemoptysis (refractory to
treatment).
• The controversy arises in cases of giant bullas Fig. 12 High-resolution computed tomography of bul-
in which some surgeons prefer operating early lous lung
delay in healing however the author has pre-

ferred using negative pressure suction as it
helps pleurodesis by increasing lung volume
and decreasing chances of atelectasis.
• NSAIDS or opioids.
• Chest physiotherapy and incentive spirometry.
Complications
• Air leak: Inside the lungs can lead to pneumo-

thorax and collapse of healthy lung tissue. To
avoid this we place the drain connected to
Fig. 13 Camera view: Bullous lung
negative suction, It should be checked rou-
tinely that the drain is patent.
to space for removing the bulla and increases • Atelectasis: Incomplete expansion of lungs
the visibility of the lungs (Fig. 13). can lead to atelectasis. Pre-op and post-op
• Next step is to locate and grasp the bulla and physiotherapy helps prevent the same.
fire the stapler across the base. In case of large • Pneumonia: Chances of infection due to an
bullas which are difficult to manipulate, the invasive process possible. Use of empirical
bulla is punctured and deflated for effortless antibiotics should be considered. Proper post-
handling. The staple line should be put in nor- op care with vitals, i.e., temperature, pulse,
mal lung tissue to avoid air leak. and BP should be monitored hourly.
• Sizing should be carefully planned, otherwise • Sputum retention: This can also be prevented
inadequate sealing due to small stapler or with help of chest physiotherapy and nebuli-
leakage in case of too large stapler, some zation if and when needed.
surgeons prefer buttressing of the staple lines
is also done to prevent air leakage.
• Chest cavity is reinstalled with normal saline Vats Decortication
and reinflation of the lungs to check for any
visible leak. The ability to completely drain the thoracic cavity,
• Pleurodesis is done with mechanical abrasion break up pockets of pleural fluid, completely visu-
along with talc or with the help of other alize all aspects of the pleural space, by thoracos-
chemicals. copy and avoid the morbidity of a thoracotomy.
• Placement of pleural drains to avoid air or VATS drainage of empyema and decortication has
fluid collection in the operated area and to become an attractive procedure in the manage-
ensure complete expansion of lung. ment of empyema and hemothorax.
• Pleurodesis works when the lung is com-
pletely expanded. Closure of the ports.
Indications
Post-op Management • An effusion which is loculated or occupying

50% of hemithorax [25].
• Drain placed can be attached to negative pres- • An infected pleural effusion.
sure suction as per the surgeon’s choice. There • An empyema of less than approximately
have been controversies regarding the use of 3 weeks, in the exudative or fibro purulent
negative pressure suction as few authors stage 4 [25].
believe it continues to have air leak and hence • Hemothorax.
• Descending mediastinitis.
• When the nature of the pleural process is undi-
agnosed, this allows for a directed pleural
biopsy that is likely to make the diagnosis while
avoiding the morbidity of a thoracotomy.
Contraindications
• Prior thoracotomy.
• Prior talc pleurodesis.
• The inability to tolerate single lung ventilation.
• Fibrothorax.
Fig. 14 High-resolution computed tomography of
empyema
Surgical Technique
• The first incision should be taken very care-

fully after accessing the computed tomogra-
phy imaging as the lungs might be adhered to
the chest wall. The camera port is placed in the
seventh or sixth intercostal space in the line of
the anterior superior iliac spine or just anterior
to this. Rest of the ports are placed as dis-
cussed above; generally, 2–3 ports are made
for drainage of empyema and hemothorax
[26]. However, in cases of dense adhesions at
the primary camera port, different positions
can be chosen for insertion of first port.
• After entering the chest wall, a Yank Auer suc- Fig. 15 Technique to peel of cortex
tion is used to drain the chest of effusion or
blood. The suction along with a finger is then • The suction and ring clamp/decortication for-
used to break up simple loculations while con- ceps are used together to remove the fibrinous
tinuing suction if necessary. The preoperative material from the pleural cavity and the
CT scan (Fig. 14) helps guide this “blind” ini- curette, peanut, and ring clamp are used to dis-
tial drainage and creates a working pleural sect the cortex on the lung (Fig. 15).
space for the thoracoscopic instruments. • At the inferior aspect of the pleural cavity, it is
Gelatinous fibrinous deposits and blood clots helpful to identify and separate the lower lobe of
are removed with a curved ring forceps/decor- the lung from the diaphragm. This plane is
tication forceps (Fig. 6a). The visceral pleural developed posteriorly and anteriorly allowing
peel can be debrided if needed using ring for- for the lung to fill the cost diaphragmatic sulcus
ceps, a curette, and a peanut dissector as in an once the decortication is complete [27]. Next,
open decortication. the posterior aspect of the pleural space is
• Once a pleural space has been created the debrided and the underlying lung is
removal of fibrinous material is performed decorticated.
over the lateral part of the pleural cavity start- • Intermittent ventilation of the lung is used to
ing from the apex of the lung and proceeding assess the completeness of the decortication
to the diaphragm or vice versa. as the dissection proceeds [28] (Fig. 16).
• Particular care should be taken with hemostasis Postoperative

both on the parietal and visceral pleura [29].
• If adequate progress is not being made or there • Chest physiotherapy and incentive spirometry.
is inadequate expansion of the lung to fill the • The chest tubes are maintained on suction to
chest, then conversion to open decortication make sure there is complete lung expansion
should be performed. Conversion to open is and adequate drainage of the pleural space.
performed when necessary and should not be • Once the drainage is less than 200 cc/24 hrs
considered a failure of thoracoscopy [30]. and the air leak has been reduced to minimum,
• Once adequate debridement has been accom- the tubes can be removed.
plished, irrigation is performed and the lung • For patients with empyema, intravenous anti-
expansion is visualized to ensure the pleural biotics are continued during postoperative
cavity is filled by the lung [31]. period and for 14 days of oral antibiotics once
• Chest tubes can be placed anteriorly and pos- the patient is discharged [32].
teriorly for air and fluid drainage.
Complications
• Inadequate lung expansion.

• Infection and recurrence [33].
• Prolonged air leak.
asic Principles: Vats Anatomical

B
Lung Resection
Types of Anatomical Lung Resection (Fig. 17)
• Pneumonectomy: complete removal of

affected lung
• Lobectomy: resection of one of the lobes of
either lung along with their respective blood
supply.
Fig. 16 VATS decortication
Fig. 17 Anatomical
lung resection
• Segmentectomy: lung segment has a separate

group of bronchi, arteries, and segmental
veins shared with the adjacent segments. A
resection based on their anatomy will not
damage other lung segments. Therefore, for
certain lesions that are restricted to one lung
segment, especially benign lesions, a segmen-
tectomy may be considered [34].
Anesthesia
General Anesthesia with Single lung ventilation

[13] by use of a double lumen endotracheal tube
or bronchial blocker. Placement of a thoracic epi-
dural catheter should be done for postoperative
pain control.
Position: Lateral decubitus position.
Approach: depends upon where surgeon Fig. 18 Illustration of the hilar structure
choice while operating.
• It is important to introduce the stapler into the
• Anterior (Fig. 7a). chest such that, once around the vessel or
• Posterior (Fig. 7b). bronchus, it exits freely on the other side and
not encumbered by other structures. This will
avoid injury to other tissues, and assure a
Procedure secure closure of the target.
• Specimen removal is achieved with the use of
• The surgical procedure is facilitated by align- a specimen bag, to minimize contact with the
ing the view of the camera with the general soft tissues at the access incision site which
direction of the dissection. Use of angled, reduces recurrence at port sites.
either at 30 or 45 from the long axis of the • In malignant cases, nodal dissection may be
scope. performed either before or after completion of
• Thorough knowledge of the hilar anatomy the pulmonary resection.
(Fig. 18) greatly enhances the safety of all of
these techniques. Vital structures such as the
phrenic nerve or recurrent laryngeal nerve Conclusion
should be identified early and preserved.
• Use of sharp, blunt, or cautery techniques is It is imperative that minimal access surgeries
also at the discretion of the surgeon’s comfort, such as VATS be taught to a surgeon in the early
as long as the individual dissection and liga- training period to shorten the learning curve as
tion of the lobar and hilar structures are multiple studies done on the same show the
observed. improvement in the prognosis of patients needing
• Pulmonary vessels and bronchi within the thoracic surgery. The morbidity and mortality
hilum are ligated separately using endoscopic have drastically decreased and hence it has been
staplers. widely accepted all over the world. VATS has
• Bronchial arteries may be cauterized or progressively replaced open thoracotomies in
clipped, or stapled in rare cases involving most thoracic surgery centers around the world
long-standing pulmonary infection. because of its safety profile in elderly patients,
better pain control, faster recovery times, and 2004;78(5):1844–5. https://doi.org/10.1016/j.

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shown to decrease the length of hospital stay society of thoracic surgeons expert consensus for
compared to open thoracotomy. the surgical treatment of hyperhidrosis. Ann Thorac
More improvements in the same are bound to Surg. 2011;91(5):1642–8. https://doi.org/10.1016/j.
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happen with time with help of young surgeons 13. Benumof JL. Physiology of the open chest and one-
and creative minds like Bozzini’s. lung ventilation. In: Anesthesia T, editor. Churchill-
Livingstone. New York: NY; 1983. p. 287–316.
14. Kux M. Thoracic endoscopic Sympathectomy
in palmar and axillary hyperhidrosis. Arch Surg.
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Part VIII
Upper Gastrointestinal Surgery:
Esophageal Surgery
Achalasia
Javier Lopez-Gutierrez and B. Mario Cervantes
Introduction Clinical Features

and Manifestations
Achalasia is the result of a progressive degenera-
tion process of the ganglion cells of the myenteric • Usually has an insidious onset of mild symp-
plexus, located in the esophageal wall. The disor- toms, with gradual progression through the
der motility that characterizes achalasia appears years.
to result primarily from the loss of inhibitory neu- • Mean duration of symptoms before proper
rons within the wall of the esophagus itself. This diagnosis is 4.7 years [4].
loss of the inhibitory innervation in the LOS • The most frequent manifestations are:
causes the basal sphincter pressure to rise and ren- –– Dysphagia for solids 91%.
ders the sphincter muscle incapable of normal –– Dysphagia for liquids 85%.
relaxation. The loss of inhibitory neurons from –– Regurgitation of undigested food or saliva
the smooth muscle portion of the esophageal body in up to 91%.
results in aperistalais [1]. The manifestations of –– Aspiration of retained material in the
the disease depend on the degree and location of esophagus.
ganglion cell loss [2]. Loss of peristalsis in the –– Vomit induction.
distal esophagus and LOS failure to relax with –– Difficulty in belching in 85%.
swallowing, both impair esophageal emptying. –– Substernal chest pain.
Most of the signs and symptoms of achalasia are –– Heartburn in 40–60%.
due to the defect in LES relaxation. –– Hiccups.
Esophagogastric junction (OGJ) outflow obstruc- –– In order to overcome the distal
tion. The risk of developing esophageal cancer obstruction:
increases up to 3.3% after a mean symptom dura- • Patients slow down when they eat.
tion of 13 years [3]. • Adopt specific maneuvers (neck lifting and
throwing the shoulders back) in order to
enhance esophageal emptying.
J. Lopez-Gutierrez (*) –– Mild weight loss.
Minimally Invasive Surgery and Gastrointestinal
Endoscopy CMN 20 de Noviembre, ISSSTE CDMX, –– Significant weight loss may suggest malig-
Mexico City, Mexico nancy (psuedoachalasia).
B. M. Cervantes
Minimally Invasive Surgery and Robotic Surgery
CMN 20 de Noviembre, ISSSTE CDMX,
Mexico city, Mexico

https://doi.org/10.1007/978-981-19-3755-2_31
202 J. Lopez-Gutierrez and B. M. Cervantes
Diagnostic Evaluation ened muscular ring with a rosette configura-

tion on retroflexed view. The contracted LOS
• Clinical History. may appear with an increase in the passage of
• Chest X-Ray. the endoscope through the esophagogastric
• Barium Swallow Study. junction. However, endoscope can usually be
• OGD: traversed easily with a gentle pressure of the
–– Dilated esophagus. endoscope. The esophageal mucosa usually
–– Food debris. appears normal [6]. Some nonspecific changes
–– Mucosal ulcerations (esophagitis). may be seen. Stasis may predispose to esopha-
–– Mild resistance on passing the endoscope geal candidiasis, which may be seen as adher-
through the union. ent whitish plaques.
• Esophageal manometry. Typical manometric
findings are:
–– Aperistalsis in the distal two-thirds of the Differential Diagnosis
esophagus.
–– Incomplete LOS relaxation. Achalasia may be misdiagnosed as gastroesopha-
–– Elevated resting LOS pressure. The loss of geal reflux disease, especially in patient with
inhibitory neurons may cause resting LOS chest pain of a burning quality of heartburn. The
pressures to rise above 45 mmHg. differential diagnosis includes other motility dis-
–– High-resolution manometry. Achalasia is orders and pseudo achalasia due to malignancy or
diagnosed by an elevated median integrated Chagas disease.
relaxation pressure (IRP), which indicates
impaired OGJ relaxation, and absence of
normal peristalsis. Treatment
• Endoscopic Ultrasound.
1. Pharmacological therapy.
Findings Include 2. Endoscopic Therapy.
(a) Pneumatic Dilation [7].
• Bird beak sign or rat-tail sign (b) Peroral endoscopic myotomy (POEM)
• Esophageal dilatation. [8].
• Pooling or stasis of barium in the esophagus (c) Botulin Toxin (BT) injection [9].
when the esophagus has become atonic or 3. Surgical Myotomy for Achalasia.
noncontractile (a late feature in the disease).
• Failure of normal peristalsis to clear the Dr. Heller described in 1913 a surgical myot-
esophagus of barium when the patient is in the omy with a fundoplication as the optimal surgical
recumbent position, with no primary waves treatment of achalasia [10]. The effectiveness of
identified. symptom control ranges from 90 to 97% of
• When the barium column is high enough (with patients [11]. The muscle fibers of the lower
the patient standing), the hydrostatic pressure esophageal sphincter are incised without disrupt-
can overcome the lower esophageal sphincter ing the mucosal lining of the esophagus. The pri-
pressure, allowing passage of esophageal con- mary goal is to relieve the functional obstruction
tent [5]. of the LOS while preventing reflux. Original
• Endoscopic evaluation to exclude malignancy Heller’s technique was modified to anterior
at the esophageal- gastric junction that can myotomy only, and nowadays, is the most com-
mimic achalasia. It may reveal a dilated mon operative procedure to treat achalasia [12].
esophagus with residual material. LOS The esophagus can be approached through the
appearance may range from normal to thick- abdomen or thorax.
Achalasia 203
Patient Selection Criteria The key component

for selecting the appropriate patient for surgical
management is to differentiate achalasia from
other motility disorders, pseudoachalasia, malig-
nancy, and mechanical obstruction.
POEM Vs Heller’s Myotomy For patients not

willing to have surgical treatment, or have rela-
tive surgical contraindications, POEM may be an
option. It is an incisionless surgery, using flexible
endoscopes. Submucosal tunneling is made, and
the dysfunctional circular muscle of the LOS is
divided leaving the longitudinal muscle layer
intact, which differs from surgical myotomy,
where both layers are incised. POEM has an
additional margin of safety. However, the inci-
dence of pneumoperitoneum or pneumothorax
remains high (up to 40%). More long-term stud-
ies are needed in order to appreciate the real
advantages and disadvantages compared with
Heller’s Myotomy, as well as to evaluate the
long-term results [14]. Fig. 1 Port placement
Contraindications Patients who prefer to avoid retraction should always be considered and can
surgery have undergone multiple prior abdominal be achieved by one of many different devices
surgeries or would be unable to tolerate the pneu- available for that purpose (Fig. 1).
moperitoneum required for the laparoscopic
procedure. Mobilization of the Gastroesophageal Junction
and Proximal Stomach
Surgical Technique 1. Incise the gastrohepatic ligament (Pars flac-

cida) in an avascular plane.
Patient Position Patient can be placed in supine, 2. Preserve the nerve of Latarjet and avoid injury
split leg position for optimal ergonomics. to an accessory or replaced hepatic artery.
Surgeon stands between the legs. The patient is 3. Divide the anterior phrenoesophageal liga-
positioned in a steep reverse Trendelenburg posi- ment and the peritoneum overlying the ante-
tion, which allows the stomach and other organs rior abdominal esophagus.
to fall away from the esophageal hiatus. 4. Preserve the anterior vagus nerve, which lies
immediately posterior to the right anterior
Abdominal Access and Port Placement We phrenoesophageal ligament.
can establish pneumoperitoneum by open Hasson 5. If a posterior partial or a total fundoplication is
technique, Veress needle, or optical trocar entry. performed, a posterior esophageal window is
After establishing the pneumoperitoneum, we created, then divide the left phrenogastric liga-
insert the first port, preferably with an optical tro- ments by dividing the short gastric arteries, start-
car. Then, four more ports (two for the surgeon, ing at the inferior pole of the spleen to the
one for the scope, and the rest for the assistant) exposed left crus of the diaphragm. In creating
are placed under direct laparoscopic vision. Liver this window, the posterior vagus nerve is identi-
fied and protected. If an anterior fundoplication

(Dor) technique is used, a posterior esophageal
window is unnecessary unless a hiatal hernia
and/or a relatively short esophagus is encoun-
tered and there is a need for further mobilization
to allow more intra-abdominal length in order to
construct a proper fundoplication.
Mobilization of the Mediastinal Oesophagus

The distal portion of the mediastinal esophagus is
mobilized to achieve sufficient length to perform a
myotomy incision that divides the entire length of
the LOS and permits a tension-free fundoplication.
Myotomy When performing the myotomy, it is

essential to have adequate visualization and Fig. 2 Esophageal myotomy
exposure in order to prevent mucosa injuries.
where the tissue plane becomes less readily
1. The cardioesophageal fat pad and the ante- identifiable. A careful layer-by-layer dissec-
rior vagus must be cleared from the esopha- tion helps prevent injury.
gus and the OGJ. 9. The total length of the myotomy should be
2. Once cleared, a myotomy is performed on 9 cm.
the esophagus and the stomach. This is done 10. It is highly advisable to perform an endo-
using a grasper in the left hand and Maryland scopic inspection of the mucosa, before the
forceps in the right hand. The muscles are next steps, in order to identify and repair any
gently split layer by layer till the submucosa mucosal perforations.
is clearly seen this would help avoid injury to 11. Perform a hiatal closure and when possible, it
the mucosa. is advisable to perform a fundoplication pro-
3. It is useful to have a stable platform and cedure, partial or total. Please refer to the fun-
lighting. A lighted bougie may be used, or doplication chapter for further details (Fig. 3).
even better, an endoscope, in order to illumi- 12. During fundoplication take care to do the fol-
nate, stretch the muscle fibers by insuffla- lowing: Place an inner row of interrupted
tion, and, therefore, facilitate their division. sutures to secure the medial aspect of the fun-
4. The anterior surface of the esophagus is com- dus to the left side of the myotomy. A second
pletely exposed, and slight tension is created by row of interrupted sutures is placed to fix the
retracting caudally with a Babcock retractor. leading edge to the right side of the myotomy.
5. The incision may be started on the stomach
or the esophagus. Intraoperative Technical Risks
6. The myotomy is performed by individual
dividing the esophageal and gastric muscle • Esophageal or gastric perforation—It ranges
fibers. Longitudinal muscle fibers are divided from 10 to 16%. The mucosal perforations,
first, which exposes the underlying circular when adverted, should be repaired with 4–0 or
muscles (Fig. 2). 5–0 absorbable monofilament suture. The Dor
7. Division of the circular layer reveals a bulging fundoplication will buttress the repair.
mucosa plane that should appear smooth and • Division of vagus nerve—It is rare. If an
white. The esophageal portion of the myot- injury to the anterior or posterior vagus nerve
omy should be approximately 6 cm in length. occurs, it is not repaired.
8. The most critical and challenging factor is to • Splenic injury—Ranges from 1 to 5%.
create a 3 cm myotomy caudal to the OGJ, • Pneumothorax.
Achalasia 205
Esophagus
Stomach
Stomach
Esophagus
Esophagus
Stomach Esophagus
Stomach
Dor Fundoplication Toupet Fundoplication
Fig. 3 Partial fundoplication
Postoperative Complications GORD If the patient underwent only a myot-

omy, the rate of GORD is higher [13]. If this hap-
The morbidity rate ranges between 1 and 10%. pened despite a fundoplication, they should be
The mortality rate is <0.1% in the first 30 days treated medically.
after the procedure [15, 16].
Other Complications Bleeding is a rare com-
Perforation It is the most common early postop- plication and is reported in approximately 3% of
erative complication and occurs in 1–7% of patients patients.
[17]. Late perforations usually result from either
direct unrecognized mucosal injury or inadvertent
thermal injury. Perforations may result in peritonitis Postoperative Care
or mediastinitis, or both, and may be life-threaten-
ing [16]. When a perforation is suspected, a water- • Analgesics.
soluble contrast radiograph should be obtained. • Antiemetics. Very important in order to avoid
Thoracic and abdominal CT scan with oral water- nausea and retching that may increase pres-
soluble contrast may show liquid extravasation and sure on the myotomy, increasing the risk of
collections on abdomen and/or thorax. OGD is con- complications.
troversial. Once the perforation is confirmed, early • Clear liquids may be started the night of the
reexploration is advisable with lavage and drainage day of the procedure, or when bowel function
placement. Primary repair may have acceptable returns.
results if performed in the first 24 hours after the • If the patient does not present dysphagia after
perforation was produced [18]. liquids, diet may be advanced to a soft diet the
following day.
Recurrent Dysphagia Is usually a late compli- • If the patient develops early symptoms sug-
cation of a Heller myotomy + fundoplication. It gestive of perforation, a contrast X-ray should
presents in 3–10% of patients [19, 20]. The most be considered. Symptoms include chest pain,
common cause is incomplete myotomy. Is more epigastric pain, fever, tachycardia, emphy-
common in patients that underwent thoracic sema (subcutaneous or mediastinal), and
approach [21]. Other reasons for dysphagia leukocytosis.
include herniated fundoplication, perihiatal scar-
ring, peptic stricture, and tumors.
References 12. Leeuwenburgh I, Scholten P, Alderliesten J, et al.

Long-term esophageal cancer risk in patients
with primary achalasia: a prospective study. Am J
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A population-based study. Neurogastroenterol Motil.
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2010;22:e256.
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14. Heller E. Extra mucous cardioplasty in chronic cardio-
N. The spectrum of esophageal motor disorders in
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Grenzgels Med Chir. 1913;27:141.
from amyloidosis. Successful treatment with pneu-
15. Zaninotto G, Constantini M, Rizzetto C, et al. Four
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hundred laparoscopic myotomies for esophageal
4. Dufrense CR, Jeyasingham K, Baker RR. Achalasia
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5. Foster PN, Stewart M, Lowe JS, Atkinson
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M. Achalasia like disorders of the oesophagus in
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Von Recklinghausen’s neurofibromatosis. Gut.
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18. Arreola-Risa C, Sinanan M, Pellegrini CA.
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20. Rosemurgy AS, Morton CA, Rosas M, et al. A single
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Resection of Gastroesophageal
Junction Submucosal Tumors
(SMTs)
Jun Liang Teh and Asim Shabbir
Introduction tric approach, transthoracic approach, and

combined laparoscopic and endoscopic
• Gastroesophageal submucosal tumors are a approach.
heterogeneous group of tumors comprising of
leiomyomas, gastrointestinal stroma tumors
(GIST), or neurogenic tumors such as schwan- I ndications
noma or neurofibroma. Other possible differ-
entials include congenital causes such as • Patient factors
duplication cysts. –– Patients fit enough to tolerate general anes-
• Leiomyomas account for two-thirds of benign thesia and undergo laparoscopy; patients who
tumors in the esophagus and stomach. One- require resection of the submucosal tumor via
third of these tumors are located in the gastro- a transthoracic approach may require single
esophageal junction. lung ventilation during the procedure.
• Leiomyomas are benign mesenchymal tumors • Disease factors
and arise in the smooth muscle cells. –– Symptomatic patients.
• Symptomatically, gastroesophageal submuco- –– Giant leiomyoma measuring greater than
sal tumors may result in dysphagia, vague chest 10 cm.
discomfort, reflux, occasional regurgitation, or –– Submucosal lesions measuring greater than
bleeding. In most other instances, asymptom- 2 cm, where histology is not available.
atic tumors may be diagnosed following screen- –– Benign submucosal tumors demonstrating
ing gastroscopy or incidentally as mediastinal an increase in size on follow-up imaging (>
masses or abdominal masses on CT scan. 1 cm/year).
• Operative technique for gastroesophageal –– Indeterminate histology on histology after
include laparoscopic approach with or with- endoscopic ultrasound (EUS) guided fine
out fundoplication, laparoscopic transgas- needle biopsy (FNA) has been performed.
J. L. Teh Contraindications
Ng Teng Fong General Hospital, National University
Health System, Singapore, Singapore
• Patient factors
A. Shabbir (*)
National University of Singapore, –– Patients with severe comorbidities
Singapore, Singapore (American Society of Anesthesiologists
e-mail: cfsasim@nus.edu.sg (ASA) score IV and V).
https://doi.org/10.1007/978-981-19-3755-2_32
208 J. L. Teh and A. Shabbir
–– Patients who are unable to tolerate laparos-

copy (relative contraindication consider
open surgery).
• Disease factors
–– Small submucosal tumors measuring lesser
than 2 cm.
Pre-op Assessment
• Upper gastrointestinal gastroscopy:

–– The size and location of the lesion is
recorded.
–– The relationship of the lesion to the gastro-
esophageal junction and lower esophageal
sphincter is assessed in order to decide the
operative technique. Fig. 1 OT set up and patient position
–– In the case of leiomyoma, rounded, mobile
lesions with normal overlying mucosa are is required, or they can be tucked in bilaterally
observed. (Fig. 1).
• Barium contrast swallow study is an alterna- 2. A footboard is placed, and the bilateral ankles
tive where gastroscopy is not available. are padded with gel pads. Crepe bandages are
• Endoscopic Ultrasound to assess-which layer applied to secure the feet to the footboard as
the tumor arises from, well as over bilateral knees to secure the
–– the ultrasonic features of the lesion,-any patient.
acoustic shadowing 3. Mechanical deep vein thrombosis prophylaxis
–– assess the presence of any mediastinal in the form of calf compressors or TED stock-
lymph nodes. ings should be instituted.
–– EUS—FNA can be used to biopsy the 4. The operating surgeon stands on the right of
lesion. the patient and the first assistant opposite the
• CT thorax/abdomen: assessment of the lesion in operating surgeon. The laparoscopy stack is
relation to the gastroesophageal junction, assess placed to the left of the patient at the level of
for metastases in the case of malignant submu- the shoulder of the patient.
cosal tumors.
–– Leiomyomas are classically intramural and
solitary on CT scan with smooth outlines Surgical Technique
and are multilobulated. The presence of cal-
cifications is pathognomonic for • Essential Steps in Synthesis.
leiomyomas. –– Safe entry and pneumoperitoneum
creation.
–– Port placement.
OT Setup –– Liver retraction for adequate visualization
of the hiatus.
Operation Room set up and patient positioning –– Hiatal dissection and mobilization of the
distal esophagus.
1. The patient is placed in supine position in the –– Excision of the GEJ SMT.
reverse Trendelenburg position. Bilateral –– Crural repair.
arms can be placed on arm boards if IV access –– Fundoplication.
Resection of Gastroesophageal Junction Submucosal Tumors (SMTs) 209
–– Liver retraction.
Liver retraction can be provided either
with a Nathanson retractor/a snake
retractor placed in the epigastric area or
the use of OR bowel forceps to retract
the liver for visualization of the hiatus.
–– Hiatal dissection and mobilization of distal
esophagus.
Entry in the lesser sac: The lesser omen-
tum is divided and dissection taken to
the level of the right crus. Any hepatic
branches of the vagi or accessory left
hepatic artery should be preserved as
much as possible.
Division of the phrenoesophageal mem-
brane: The phrenoesophageal mem-
Fig. 2 Port placement brane is divided from the right crus
toward the left crus.
Blunt dissection of the hiatus and mobi-
• Description of the technique. lization of the esophagus: The areolar
tissue between the esophagus and the
–– Abdominal access for pneumoperitoneum. diaphragmatic crus can easily be mobi-
Pneumoperitoneum is established using lized by blunt dissection or using an
the surgeon’s preferred method for energy device. When dissecting the hia-
abdominal entry. Options include the tus, care must be taken to avoid injury to
use of a Veress needle at the Palmar’s the abdominal aorta which lies just pos-
point, open Hasson technique, or the use terior to the esophagus.
of optical entry. Creation of retroesophageal window
–– We perform optical entry using a 12 mm (only required if performing posterior
disposable optical entry port. Port fundoplication or lesion is located pos-
Placement (Fig. 2). teriorly): Using a suction device or a
The initial trocar site for pneumoperito- grasper, a posterior esophageal window
neum is made 1/3 the distance up is created by bluntly dissecting the pos-
between the umbilicus and the xiphoid terior adventitia tissue. Care must be
process, about three finger breaths to the taken not to injure the posterior vagus.
left of the midline, this corresponds to Once the window is created, a nylon tap
the left mid clavicular line. helps sling the esophagus and used for
A 12 mm port is placed to the right of retraction by the assistant to facilitate
the umbilicus (surgeon’s right hand) and exposure and dissection.
another 5 mm port (surgeon’s left hand) –– Excision of the GEJ SMT.
is placed in the right subcostal area. For submucosal tumors that are away
Triangulation provided by these two from the GEJ along the lesser curve,
working ports should allow the operat- wedge resection can be performed pro-
ing surgeon good access to the fundus of vided narrowing the GEJ can be avoided.
the stomach. Prevention of stenosis: A orogastric
A 5 mm port is placed in the left subcos- Bougie inserted into the stomach helps
tal area as the assistant port to aid retrac- to prevent stenosis at the gastroesopha-
tion if necessary. geal junction.
210 J. L. Teh and A. Shabbir
–– Crural repair and reconstruction of the

phrenoesophageal ligament.
Posterior crural repair: simple inter-
rupted or figure of eight sutures using
2/0 nonabsorbable sutures like ethibond
are used to approximate the left and
right crus.
The esophagus is fixed to the central
tendon of the diaphragm with absorb-
able suture.
–– Fundoplication.
In patients with GEJ SMT, excision of
the lesion will result in disruption of the
Fig. 3 Stapling of the lesser curve submucosal tumor lower esophageal sphincter fibers
thereby predisposing to reflux postop-
eratively. Fundoplication is performed
Excision of the tumor (Fig. 3):Once iso- to reduce the incidence and severity of
lated, excision of the tumor can then be reflux post GEJ lesion excision. A wrap
performed with a laparoscopic linear commensurate to the site of excision
cutter stapler. When performing tumor may offer the additional advantage of
excision using the stapler technique, a mitigating the effects of leakage from
30 mm stapler can be utilized for the the repair of the GEJ excision site.
first fire as it is of a smaller profile and Please refer to the chapter on gastro-
offers better maneuverability. esophageal reflux disease for details on
Subsequent stapler fires may be per- fundoplication.
formed with 45 mm or 60 mm staplers. –– Conclusion
In cases where a full-thickness excision Careful hemostasis.
of the lesion is performed with an energy Removal of the esophageal sling if used.
device, the resultant defect is closed in a Removal of all laparoscopic ports under
single layer using an absorbable 3/0 vision and evacuation of
barbed suture run continuously. pneumoperitoneum.
Leak test: an optional leak test can then Typically, surgical drain placement is
be performed using air insufflation with not required.
gastroscopy or injection of methylene
blue via the orogastric bougie.
Where the tumor encroaches upon GEJ Complications and Management
and the lower esophageal sphincter
(LES), local excision may not be possi- • Postoperative hemorrhage.
ble due to high likelihood of stenosis –– Hemostasis must be observed intraopera-
and injury to LES under such circum- tively and bleeding of the stapler line
stance proximal gastrectomy should be secured with either diathermy or suture
considered. ligation prior to ending the procedure.
Resection of Gastroesophageal Junction Submucosal Tumors (SMTs) 211
–– Postoperative bleeding is usually reactive in • Gas Bloat syndrome: conservative manage-

nature and is either from cut edge of the ment and routine counseling to avoid exces-
omentum or the stapler line. A trial of con- sive aerophagia.
servative therapy may be attempted in
hemodynamically stable patients with
packed cell transfusion as necessary. Post-op Care
Reexploration may be required if there is
evidence of ongoing hemorrhage, hemody- • Regular and adequate analgesia is prescribed.
namic instability, or low hemoglobin counts In our unit, we typically prescribe intravenous
despite transfusion. paracetamol 1 g q.d.s. Breakthrough pain is
• Leakage from the repair site. managed with opiates on PRN basis.
–– Perforation and leakage resulting from the Aggressive prophylaxis against postoperative
stapler line or repair site may happen infre- nausea and vomiting.
quently (1–3%). • The patient is started on proton pump inhibitor
–– In most cases, expedient reexploration is therapy. PPI therapy can be discontinued after
necessary. Surgical principles include fash- 4 weeks if the patient has symptoms of reflux
ioning of the defect, repairing the defect, or dyspepsia following surgery.
abdominal washout, and placement of • The patient is started on clear liquids on the
drains. In cases not amenable to repair, a day of surgery and liquid diet on postopera-
proximal gastrectomy and distal esopha- tive day 1 and minced diet on postoperative
gectomy may be required. day 2.
• Postoperative dysphagia: managed initially • Patients who are clinically well and able to
with conservative therapy with a liquid diet. tolerate diet on postoperative day 2 can be
Consider endoscopy and balloon dilatation or safely discharged.
revision surgery if symptoms are severe and • The patients were reviewed in the outpatient
persistent. clinic 2 weeks and 1 month after surgery.
Transoral Endoscopic Zenker
Diverticulotomy
Christina H. L. Ng and Chwee Ming Lim
Introduction geal reflux disease (GERD) and hiatus hernia,

although the causal relationship between these
Zenker’s diverticulum is an outpouching that conditions has not been established [3, 4].
emerges from Killian’s triangle dehiscence,
formed by oblique fibers of the inferior pharyn-
geal constrictor muscle and cricopharyngeus Clinical Features
muscle. The reported prevalence lies between
0.01 and 0.11% and affects predominantly • Small diverticula are typically asymptomatic
middle-aged and elderly patients [1]. and may be detected incidentally on cross-
sectional imaging such as computed tomogra-
phy of the neck (CT neck).
Pathophysiology • Larger diverticulum (typically more than
1 cm)—patients may present with halitosis,
The development of Zenker’s diverticulum is gurgling in the throat, regurgitation of food
proposed to be due to cricopharyngeal dysfunc- into the mouth, dysphagia, and even frank
tion (CPD). In CPD, repeated discoordination aspiration symptoms. In those with longstand-
between the upper esophageal relaxation and ing dysphagia, they may present with signifi-
pharyngeal contraction during deglutition results cant weight loss and malnourishment [5].
in perpetual increased intra-esophageal pressure Examination of the head and neck region is
contributing to the development of the outpouch- usually unremarkable. On flexible nasopha-
ing over the anatomic weakness of the Killian ryngoscopy, there may be pooling of saliva in
dehiscence [2]. Similarly, patients with Zenker’s the hypopharynx. Occasionally, a soft swelling
diverticulum may have coexisting gastroesopha- in the neck with a positive Boyce’s sign may be
present. Boyce’s sign refers to the presence of
C. H. L. Ng a splashing sound during palpation over the
Department of Otorhinolaryngology-Head and Neck soft swelling in the neck. This is due to accu-
Surgery, Singapore General Hospital, mulated fluid within the diverticulum.
C. M. Lim (*)
Department of Otorhinolaryngology-Head and Neck
Surgery, Singapore General Hospital, Investigations
Surgery Academic Clinical Programme, Duke-NUS 1. Barium swallow test.
Medical School, Singapore, Singapore 2. CT neck.
https://doi.org/10.1007/978-981-19-3755-2_33
214 C. H. L. Ng and C. M. Lim
3. Functional endoscopic evaluation of swallow- associated with an open approach were more
ing (FEES) and/or Video fluoroscopy (VFS). severe including recurrent laryngeal nerve injury
(3.3%) and esophageal perforation (3.3%) [8].
These investigations are performed when the Transoral approach has a shorter operation time
clinical suspicion of aspiration is high. VFS can and shorter length of stay [9]. However, failures
also be used to assess the narrowing of pharyngo- associated with a transoral approach lie in the dif-
esophageal sphincter and persistent prominence ficulty of adequate visualization of the surgical
of cricopharyngeus muscle termed as the crico- field; and incomplete division of party wall
pharyngeal bar [6]. resulting in an inferior ridge [10].
Treatment Options Contraindications
Surgery is indicated for patients with symptom- Incidental small Zenker’s diverticulum of less
atic Zenker’s diverticulum. Most patients with a than 1 cm does not require any surgical interven-
small diverticulum (usually less than 1 cm) are tion as these patients are usually asymptomatic.
usually asymptomatic. Contraindications for a transoral approach
Surgery can be broadly divided into endo- include factors that preclude adequate exposure
scopic transoral versus an open transcervical of the hypopharynx. These factors can be sum-
approach. In the transoral endoscopic assisted marized according to the 8 Ts of endoscopic
approach, the aim of surgery is to divide the access: teeth, trismus, transverse dimensions
“party septal wall” between neck of the diverticu- (mandibular), tori (mandibular), tongue, tilt
lum and true esophageal opening. This procedure (atlanto-occipital extension), treatment (prior
creates a common cavity between the esophageal radiotherapy), and tumor [11].
lumen and diverticulum. Table 1 summarizes the
pros and cons of these two approaches.
Overall, transoral endoscopic approach has Preoperative Assessment
lower morbidity of 8.7% as compared to open
approach of 10.5%. The most common complica- A barium swallow test should be done to confirm
tions associated with transoral approach are cer- the diagnosis of a Zenker diverticulum, and to
vical emphysema (2.2%), perforation (1.4%), assess swallowing and the length of diverticulum
and dental injury (1.1%); whereas complications (Fig. 1). Additionally, staging system can be
Table 1 Summary of the pros and cons of open versus endoscopic approach
Open approach Transoral endoscopic approach
Pros Lower risk of symptom recurrence Less invasive
Shorter operating time
Shorter length of hospitalization
Earlier diet introduction
Lower rate of complications
Easy access in case of recurrence
Cons More invasive Higher rates of symptom
Longer operating time (standardized mean difference 78.06 min, recurrence
95% CI 90.63,65.48) [7].
Longer length of hospitalization
Longer time to diet introduction
Higher rate of complications including recurrent laryngeal nerve
injury
Transoral Endoscopic Zenker Diverticulotomy 215
Fig. 1 Barium swallow (lateral view) demonstrating

Zenker’s diverticulum
Fig. 2 Endoscopic exposure of Zenker’s diverticulum sac

assessed on barium swallow test using Morton’s and septum between the diverticular sac and cervical
esophagus—with food debris seen in diverticulum sac
staging system [12].
1. Small sacs are less than 2 cm in length. • The rigid Weerda diverticuloscope (Karl
2. Intermediate sacs are 2–4 cm in length. Storz, Tuttlingen, Germany) is placed with
3. Large sacs are greater than 4 cm in length. anterior blade into the lumen of esophagus
and posterior blade in the diverticular sac. The
diverticuloscope is opened proximally suffi-
OT Setup and Equipment Required ciently in order to allow a zero-degree 4 mm
telescope and stapler insertion.
• Supine position with head donut and no shoul- • Once a good exposure of the party wall is
der roll. accomplished, the 12 mm endo-GIA 30 sta-
• TV tower system monitor at the patient’s foot. pler (US Surgical Corp, Norwalk, CT) is
• Weerda diverticuloscope. inserted to engage septum between diverticu-
• Long suction device. lum sac and esophagus under direct vision.
Some surgeons recommend two stay sutures
to be applied on both sides of the cricopharyn-
Surgical Technique geus muscle in order to retract the party wall
for ease of stapling. This step can also mini-
• Patient is put under general anesthesia with mize any remnant inferior ridge left in situ
complete muscle paralysis. after the stapling process.
• Rigid esophagoscopy is performed to examine • Once endo-stapling of the party wall is accom-
the entire length of the cervical esophagus. plished, the divided party wall is inspected
• The scope is then slowly removed until the using an endoscope to ensure that there is no
diverticulum is encountered at the level of cri- residual inferior ridge. The stapler line is also
copharyngeus before removing completely. inspected to ensure complete closure and
This allows confirmation of the diagnosis and hemostasis.
facilitated the identification of the true esopha- • The summary of the surgical steps is presented
geal lumen and the lumen of the diverticulum. in (Figs. 2, 3, and 4)
216 C. H. L. Ng and C. M. Lim
ous emphysema and possibly mediastinitis if

undiagnosed intraoperatively.
• Bleeding—endolaryngeal bipolar diathermy
can be used to achieve hemostasis.
Postoperative care
1. Keep nil by mouth for 24–48 h.

2. Gastrograffin swallow to be performed
24–48 h postoperatively. If there is no esopha-
geal leak noted, oral liquid diet can be started
for approximately 1 week before progressing
to semi-solid diet in the next 2–4 weeks.
3. Antibiotics coverage for 1 week (covering
broad spectrum bacteria including anaerobes.
Clindamycin is a good alternative for those
patients who are allergic to pencillin-based
antibiotic.
4. Adequate analgesia.
Fig. 3 Endoscopic exposure of Zenker’s diverticulum sac
and septum between the diverticular sac and cervical
esophagus
Conclusion
Transoral endoscopic Zenker diverticulotomy is

a minimally invasive approach that is effective
and safe to improve symptom control among
patients with this condition. Appropriate patient
selection and complete division of the septal
party wall between the diverticulum and true
esophageal lumen are key pointers towards a suc-
cessful clinical outcome.
References
1. Bizzotto A, Iacopini F, Landi R, Costamagna
G. Zenker's diverticulum: exploring treatment options.
Acta Otorhinolaryngol Ital. 2013;33(4):219–29.
2. Westrin KM, And SE, Carlsöö B. Zenker's diver-
ticulum–a historical review and trends in therapy.
Fig. 4 Septum stapled to the inferior end of the Acta Otolaryngol. 1996;116(3):351–60. https://doi.
diverticulum org/10.3109/00016489609137857.
3. Sasaki CT, Ross DA, Hundal J. Association between
Zenker diverticulum and gastroesophageal reflux
Complications and Management disease: development of a working hypothesis. Am
J Med. 2003;115(Suppl 3A):169S–71S. https://doi.
org/10.1016/s0002-9343(03)00218-3.
• Pain or discomfort of the throat—usually tem- 4. Gage-White L. Incidence of Zenker's diverticulum
porary and resolve by 1–2 days. with hiatus hernia. Laryngoscope. 1988;98(5):527–30.
• Esophageal perforation leading to subcutane- https://doi.org/10.1288/00005537-198805000-00010.
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5. Prisman E, Genden EM. Zenker diverticulum. national baselines for auditing clinical outcomes in
Otolaryngol Clin N Am. 2013;46(6):1101–11. https:// the United Kingdom. Eur Arch Otorhinolaryngol.
doi.org/10.1016/j.otc.2013.08.011. 2012;269(8):1877–84. https://doi.org/10.1007/
6. Muñoz AA, Shapiro J, Cuddy LD, Misono S, s00405-012-1945-3.
Bhattacharyya N. Videofluoroscopic findings in dys- 10. Verdonck J, Morton RP. Systematic review on
phagic patients with cricopharyngeal dysfunction: treatment of Zenker's diverticulum. Eur Arch
before and after open cricopharyngeal myotomy. Ann Otorhinolaryngol. 2015;272(11):3095–107. https://
Otol Rhinol Laryngol. 2007;116(1):49–56. https:// doi.org/10.1007/s00405-014-3267-0.
doi.org/10.1177/000348940711600109. 11. Rich JT, Milov S, Lewis JS Jr, Thorstad WL, Adkins
7. Albers DV, Kondo A, Bernardo WM, et al. Endoscopic DR, Haughey BH. Transoral laser microsurgery
versus surgical approach in the treatment of Zenker's (TLM) +/− adjuvant therapy for advanced stage oro-
diverticulum: systematic review and meta-analysis. pharyngeal cancer: outcomes and prognostic factors.
Endosc Int Open. 2016;4(6):E678–86. https://doi. Laryngoscope. 2009;119(9):1709–19. https://doi.
org/10.1055/s-0042-106203. org/10.1002/lary.20552.
8. Yuan Y, Zhao YF, Hu Y, Chen LQ. Surgical treatment 12. Ernster JA, Meyers AD. Zenker Diverticulum. 2020.
of Zenker's diverticulum. Dig Surg. 2013;30(3):207– https://emedicine.medscape.com/article/836858-
18. https://doi.org/10.1159/000351433. overview#a1. Accessed 28 June 2020.
9. Leong SC, Wilkie MD, Webb CJ. Endoscopic
stapling of Zenker's diverticulum: establishing
Gastroesophageal Reflux Disease
Adam Frankel and B. Mark Smithers
Introduction terior 270 vs 360° [7]. The relative merits of each

have been recently reviewed by Morino and col-
Gastroesophageal reflux disease (GORD) is leagues [8]. Fundoplication is at least as safe and
defined as troublesome symptoms and/or injury effective as PPI in relieving the symptoms of
to the esophageal mucosa consistent with acid GORD [9]. For PPI-refractory GORD, fundopli-
exposure [1]. GORD is common, with an age- cation is more effective than escalating medical
adjusted global prevalence of 9% but significant therapy [10].
variation across the world [2]. The diagnosis can
often be made on clinical grounds and is more
likely if there is at least a partial response to a Indications
proton pump inhibitor (PPI) [3]. Indications for
oesophageal testing have been recently updated • Established GORD, with ongoing trouble-
in international consensus guidelines, which some symptoms or complications (e.g., reflux
include guidelines where diagnosis is not clearly esophagitis).
established [4]. Fundoplication is the use of the • Trial of maximal medical therapy (MMT) or
gastric fundus to create a high-pressure zone on intolerance of medical therapy [11]. (MMT
or around the lower oesophagus and is usually often interpreted as twice daily proton pump
performed laparoscopically. It can be considered inhibitor (PPI)).
in terms of the completeness of the wrap (gener-
ally from 90 to 360°), and if less than 360°,
whether the wrap is brought anterior to the Contraindications (Relative)
oesophagus, posterior, or both. The efficacy and
side effect profiles of many of the approaches • Unfit for general anaesthetic (e.g., major med-
have been subjected to randomised trials: anterior ical comorbidity).
90 vs 360° [5]; anterior 180 vs 360° [6]; and pos- • Unsafe (e.g., prior complex upper abdominal
surgery or injury).
• Severe oesophageal dysmotility.
A. Frankel (*) · B. M. Smithers

Upper Gastro-intestinal and Soft Tissue Unit, re-op Assessment (Diagnosis
P
Princess Alexandra Hospital, Brisbane, Australia Established)
Academy of Surgery, The University of Queensland,
Brisbane, Australia Assess safety to undergo GA/operation.
https://doi.org/10.1007/978-981-19-3755-2_34
220 A. Frankel and B. M. Smithers
Preoperative education on the procedure and • Liver retraction to expose the entire hiatus.
the likely postoperative course • Fat retraction suture to expose the entire fun-
dus and the superior pole of spleen.
• all patients will experience port site pain, • Mobilise fundus to allow a loose wrap. Separate
• many will get referred shoulder pain (capno- from left diaphragm, usually with division of
peritoneum and diaphragmatic manipulation/ superior short gastrics.
suturing), • Dissect the hiatus, by dividing phrenoesopha-
• some get chest pain (oesophageal spasm, geal ligament, and mobilise the distal esopha-
extensive hiatal dissection), gus to achieve an adequate intra-abdominal
• likely one night as inpatient, length.
• diet upgraded from liquid to soft over time • Restore the normal anatomy, perform cruro-
(weeks), plasty, reconstitute the phrenoesophageal
• in-depth discussion on possible side effects attachment.
(especially gas-bloat and flatulence). • Create the wrap. Fix the fundus to the dia-
phragm and oesophagus.
OT Setup
Description of the Technique
Instrumentation
Patient’s Position
• 3× 5 mm ports (one replaced with 12 mm if
cut-down approach preferred or 10 mm cam- Lithotomy
era required), 1× 8 mm port • We favor the ergonomics of lithotomy with
• 5 mm 30 deg laparoscope (10 mm if using 12 both arms out; Allen’s stirrups (padded leg
mm port) supports) with reverse Trendelenburg; thighs
• Nathanson retractor—alternative is a ratch- horizontal.
eted toothed grasper (requires via an addi- • Surgeon between legs, camera operator seated
tional 5 mm port in the epigastrium). on patient’s left, instrument nurse +/− assis-
• 2× laparoscopic atraumatic graspers (e.g., tant on right.
Johan, DeBakey)
• Advanced energy device—author preference
is Ligasure with Maryland-tip. Alternative, Patient supine
• Laparoscopic scissors, needle holder, and • Surgeon on the patient’s left, assistant right
suction. side.
• Portex sling. • Bed mount for Nathanson retractor on patient’s
• Mechanical and chemical prophylaxis and right.
antibiotics per local guidelines.
Entry (Site for the Laparoscope)

Surgical Technique
• Approximately 5 cm below the costal margin
Essential Steps in Synthesis in midclavicular line. Excellent view of the
gastro-splenic region and the left crus of the
• Optimal positioning. diaphragm especially in obese patients.
• Consider patient safety, operative access, and (Fig. 1).
surgeon ergonomics. • Optical entry or open cut-down with Hasson’s
• Safe entry and appropriate port placement. cannula.
• Adequate view.
Gastroesophageal Reflux Disease 221
Omental retraction—Omental suture
• Via left lateral port, full length 2/0 polypropyl-

ene, artery clip on free end outside the body,
multiple bites of omental fa, attached to supe-
rior greater curve overlying/covering the short
gastric vessels. Needle removed via same
port, port removed then reinserted with both
arms of suture outside the port. Both suture
arms secured with artery clip at skin level
once adequate retraction. Retraction under
vision monitoring the spleen, with cessation
of retraction if any splenic movement.
• For obese patients, a retraction suture can be
helpful on the lesser omentum to improve
visualisation of the right crus and posterior
Fig. 1 Port placement hiatus.
Dissection
Other Ports Limited division of superior short gastric vessels
with Ligasure to allow sufficient mobility of fun-
Placed under vision after local anaesthetic dus for the wrap.
infiltration.
Precise location per surgeon preference and • Assistant retracts the fundus to the right to
varied slightly for patient anatomy. expose short gastric vessels.
We use: • If the gastro-splenic distance is very short,
Surgeon’s ports: 5 mm port—just right of mid- divide the peritoneum overlying the vessels as
line for left hand; 8 (or 12) mm port left lateral well as the peritoneal reflection from the fun-
upper quadrant, anterior to the tip of ninth rib for dus to the diaphragm first. This allows the ves-
right hand. sels to lengthen and be divided with safety,
avoiding physical or thermal injury to the
• This port is used for needle and sling introduc- stomach wall or splenic capsule.
tion and removal and as the exit site of the fat
retraction suture. Exposure and sharp division of the left phren-
oesophageal ligament.
Retraction port (assistant): 5 mm right upper
quadrant • Continue phrenoesophgeal ligament division
anteriorly as far as possible to the right.
• Retraction and oesophageal sling manoeuvering,
• Liver retraction port: 5 mm sub-xiphisternal Expose the right crus.
incision for Nathanson retractor. Alternatively,
5 mm port for ratcheted toothed grasper placed • Assistant grasps anterior cardia fat pad and
under left lobe of liver, attached to diaphragm pushes to the left.
2 cm above the right crus. • Divide the superior lesser omentum with the
Ligasure. It is rare to need to divide as low as
xposure to Commence Fundal Short
E the pars flaccida; open a few centimeters supe-
Gastric Division (Fig. 2) riorly and preserve the hepatic branch/es of
Liver retraction—Nathanson retractor or grasper the vagus). Similarly, an aberrant left hepatic
(as above). artery, if present, should be preserved.
Suture retraction
Nathanson’s of fat over upper
liver retractor fundus
Gastric fundus
Site to commence
grasped and
division of short
retracted to the
gastric arteries.
right
Fig. 2 Fat retraction and site of commencement of short gastric division
Complete dissection of the right phrenoesoph- (see above). Both ends of the sling are taken
ageal ligament out of the port and an artery forceps applied
without tension.
• Sharp and blunt dissection to meet the dissec- • The two segments of the sling can be grasped
tion from the left. close to the anterior oesophago-gastric junc-
• Anterior and posterior vagi must be identified tion by the assistant allowing the lower
and preserved. oesophagus to be manipulated.
Bluntly dissect posteriorly. Complete the anterior hiatal dissection
• Typically, with the suction device using blunt • With distal sling retraction, dissect the loose
dissection, aiming to be between the posterior areolar tissue off the oesophagus. The anterior
oesophageal wall and the posterior vagus so vagus usually runs on the oesophageal wall
that it is excluded from the wrap. This is and is preserved.
because unlike the anterior vagus, the poste-
rior vagus is not closely applied to the oesoph- Complete the posterior hiatal dissection
ageal wall. After coming through the hiatus it
turns abruptly posteriorly so that the majority • Assistant lifts the sling anteriorly. Approach
of its fibres can join the coeliac and superior from the right aspect with the 30 deg scope
mesenteric plexuses. In the uncommon sce- angled to look to the left.
nario of the posterior vagus not easily separat- • Clear tissue posteriorly to identify the left crus
ing from the oesophagus it can be included in through the window.
the wrap. • If the posterior vagus was not included in the
sling, it should be identified and pushed
Pass a sling around the esophagus posteriorly.
• There should be a window for the wrap to be
• Pass a blunt grasper behind the oesophagus brought through.
from right to left. View the grasper tip ante-
rior to the left crus and bring in the sling via Relax the sling and ensure an adequate intra-
the left lateral port, passing it behind the abdominal length of esophagus, which should be
oesophagus but in front of the posterior vagus around 2 cm.
Oesophagus
retracted
superiorly and
Right crus of distally by the
diaphragm sling (not shown)
Suture left and

right crura “Window’
posterior to the
oesophagus.
Upper pole of
spleen seen
Fig. 3 Approximation of the right and left crus posterior to oesophagus
losure of the Hiatus (Fig. 3)

C Assistant retracts the sling to the patient’s
Approximate the posterior right and left crura right to identify the left crus.
Approximate the oesophagus muscle wall to
• Use interrupted 2/0 Novofil incorporating the left crus.
crural muscle and overlying connective tis-
sue (otherwise at risk of the suture cutting • 3/0 Prolene or PDS continuous suture from 6
through). Note that the bulk of the left crus is o’clock to 1 o’clock position
anterior requiring only a modest bite with • Modest bites of the left crural pillar and the
the suture, while the right crus is thinner and oesophageal muscularis propria.
a larger bite should be considered (ensuring
no injury to the inferior vena cava). The left Fundoplication—Nissen or Toupet
crus is usually also longer (semi-circular) (Fig. 4)
than the more vertical and straight right crus, Conceptually, the fundus is taken behind the
often necessitating asymmetric bites to oesophagus with the angle of His being the pivot
ensure an appropriately-shaped hiatus is point and not rotated or displaced
created.
• Loosen the left omental retraction suture/s.
• Closure should be enough for an anterior hia-
• Left-hand grasper posterior to the oesophagus,
tal space that would allow two blunt graspers
right-hand grasper places the apex of the fun-
to be placed (without difficulty).
dus into the left grasper.
• Typically, one posterior suture is all that is
• Bring the left grasper through the window to
required, if no hiatus hernia or minimal her-
position the fundus on the right aspect of the
niation is present. (Anterior hiatal suture clo-
intra-abdominal oesophagus.
sure is typically only required for giant hiatus
• The segment of fundus is brought through
hernias with large hiatal defect and attenuated
more easily by grasping along the line of the
left crus.)
superior/greater curve portion rather than the
lower/distal portion of the fundus as it appears
Reconstruction of the Left
on the right side of the oesophagus.
Phrenoesophageal Ligament
This helps maintain an adequate intra-abdominal A two-handed “toweling” maneuver can help
length of oesophagus and discourages herniation to set the fundus in position.
through the space, which, in our early experi-
ence, was the most common site for fundal hiatal • The divided short gastric vessels should lie
herniation. anteriorly on the right, and the wrap should sit
a
Divided short
gastric vessels
Oesophagus
Fundus taken to Upper greater

the right side of curve
oesophagus
Sling retracted
inferiorly.
b c
Fig. 4 (a) Fundus taken posterior to the oesophagus to the right—“toweling” maneuver to ensure no tension. (b)
Completed fundoplication—Nissen (360 ). (c) Completed fundoplication—Toupet (270)
in position without tension. (If not, consider Nissen Fundoplication

dividing another short gastric vessel).
• The assistant grasps the right portion of the Left and right fundus sutured together anterior to
fundus while surgeon gets the sutures. At this the oesophagus with 2 x nonabsorbable sutures
time, a bougie can also be passed by (2/0 Novofil)
the anaesthetist.
• Bites of the seromuscular layer of the stom-
Oesophageal bougie passed by anaesthetist. ach, the muscularis propria of the esophagus
(avoiding the anterior vagus nerve), and the
• We routinely calibrate the hiatal closure with a seromuscular layer of the right fundus that had
48Fr (small female) to 54Fr (large male) been held by the assistant.
bougie. • The assistant grasps the cardial fat pad to push
• Any tension on the sling is released. The anaes- posteriorly and retract distally after the suture
thetist announces that it is being pushed dis- is placed and before the suture is tied.
tally with slow, cautious passage through the • The suture is tied. There should be minimal to
distal oesophagus into the stomach, carefully no tension. If there is high tension then the
watched by the surgeon with close suture should be removed and redone follow-
communication. ing manipulation of the fundal wrap.
• Bougie is left in place while suturing the • A second interrupted suture, 2 cm distal to the
fundus. first, performed in the same manner.
oupet Fundoplication (the authors’

T ing a bite of the lower antero-medial fundus
preferred option) and the left oesophago-gastric junction.
• The suture is progressed superiorly, between
The right fundus is fixed to the hiatus and oesoph- the antero-medial fundus and the left lateral
agus followed by the left fundus fixed in the same oesophagus, up to the hiatus with the last bite
way. including the left crus.
• At the 10 o’clock position, using a nonabsorb- The fundus is folded 180° over the anterior
able suture (2/0 Novofil), a bite is taken of the oesophagus
oesophageal muscularis propria, the right crus
and the fundus and tied. • Starting superiorly, using a new nonabsorb-
• The assistant grasps the cardial fat pad to able suture (2/0 Novofil), take a bite of stom-
retract distally and push posteriorly to allow a ach, oesophagus, and upper right crus at apex
good view of both fundal components and and suture tied.
anterior oesophagus. • A continuous suture is progressed inferi-
• A continuous suture is run picking up oesoph- orly, picking up the fundus, the right lateral
agus and fundus for 2 cm and tied. oesophagus, and two further bites of the
• This is then repeated on the left commencing right crus.
at the 1 o’clock position. • This is continued on the right lateral esopha-
• The anterior vagus is avoided and should lie gus to the oesophago-gastric junction where
between the two suture lines. the suture is tied.
• Remove bougie.
• Gastropexy (after Nissan or Toupet fundo-
plication) using 2/0 Novofil interrupted Conclusion
suture to fix the fundus to the crura (7
o’clock on the right crus and 5 o’clock on Remove sling, retraction suture/s, Nathanson
the left crus). This may help to prevent recur- retractor under vision.
rence, which usually occurs on the left and Complete evacuation of capnoperitoneum
posteriorly. (reduces postoperative pain).
Ports removed under vision.
Skin closure and dressings per surgeon
Fundoplication—Anterior preference.
Mobilization of oesophagus from the hiatus as

described earlier Complications and Management
• There is rarely a need for the division of the Subcutaneous emphysema—ensure no airway
short gastric branches. compromise prior to extubation, then
• Ensure an adequate length of intra-abdominal simple observation.
oesophagus. Capnothorax—due to pleural injury; observa-
• There is no need for an oesophageal bougie. tion is usually sufficient but evacuate capnothorax
and capnoperitoneum if intra-operative cardio-
Trial of wrapping anterior fundus across the vascular or respiratory compromise.
oesophagus. Oesophageal spasm—see below (presents as
Fixation of the angle of His and left severe chest pain in recovery or in the first few
oesophagus postoperative days).
Early dysphagia—best avoided with careful
• Using a continuous nonabsorbable suture (2/0 patient selection and intra-operative calibration
Novofil), the angle of His is recreated by tak- of the wrap around a bougie; manage with restric-
tion of diet (liquids); if severe then consider early References

endoscopy and/or reoperation.
Gas bloating—preoperative counseling (avoid- 1. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones
R. The Montreal definition and classification of gas-
ance of excessive swallowing/aerophagia), postop- troesophageal reflux disease: a global evidence-based
erative counseling, cognitive behavioral therapy. consensus. Am J Gastroenterol. 2006;101(8):1900–
Excessive flatulence—as above. 20. quiz 43
Late dysphagia—possible causes include hia- 2. Dirac MA, Safiri S, Tsoi D, Adedoyin RA, Afshin A,
Akhlaghi N, et al. The global, regional, and national
tus hernia or wrap failure allowing erosive burden of gastro-oesophageal reflux disease in 195
oesophageal injury or stricture; at clinician’s dis- countries and territories, 1990–2017: a systematic
cretion, swallow study, CT, or endoscopy. Also, analysis for the global burden of disease study 2017.
consider non-GORD diagnoses such as oesopha- Lancet Gastroenterol Hepatol. 2020;5(6):561–81.
3. Savarino E, Bredenoord AJ, Fox M, Pandolfino JE,
geal dysmotility or malignancy. Roman S, Gyawali CP, et al. Advances in the physi-
ological assessment and diagnosis of GERD. Nat Rev
Gastroenterol Hepatol. 2017;14(11):665–76.
Post-op Care 4. Gyawali CP, Kahrilas PJ, Savarino E, Zerbib F, Mion
F, Smout AJPM, et al. Modern diagnosis of GERD:
the Lyon consensus. Gut. 2018;67(7):1351–62.
Regular simple analgesia, stronger analgesia (e.g. 5. Hopkins RJ, Irvine T, Jamieson GG, Devitt PG,
opiate) as required but this isn't common. Watson DI. Long-term follow-up of two randomized
Dull central chest pain is usually from oesoph- trials comparing laparoscopic Nissen 360° with ante-
rior 90° partial fundoplication. BJS (British Journal of
ageal spasm. Surgery). 2020;107(1):56–63.
6. Cai W, Watson DI, Lally CJ, Devitt PG, Game PA,
• In patients with risk factors for ischaemic Jamieson GG. Ten-year clinical outcome of a pro-
heart disease, exclude acute coronary spective randomized clinical trial of laparoscopic
Nissen versus anterior 180(degrees) partial fundopli-
syndrome. cation. Br J Surg. 2008;95(12):1501–5.
• Treat with reassurance, sitting upright, slow 7. Du X, Hu Z, Yan C, Zhang C, Wang Z, Wu J. A meta-
deep breathing, and a trial of IV hyoscine analysis of long follow-up outcomes of laparoscopic
butylbromide (Buscopan), sublingual glyceryl Nissen (total) versus Toupet (270°) fundoplication for
gastro-esophageal reflux disease based on random-
trinitrate, or an oral calcium channel blocker if ized controlled trials in adults. BMC Gastroenterol.
no contraindications exist. Opiates are not 2016;16(1):88.
always helpful and can cause vomiting; con- 8. Morino M, Ugliono E, Allaix ME, Rebecchi
sider a small dose of anxiolytic (e.g., 1 mg F. Laparoscopic surgery for gastroesophageal reflux
disease: Nissen, Toupet or anterior fundoplication
midazolam). Ann Laparosc Endosc Surgery 2019;4.
9. Galmiche J-P, Hatlebakk J, Attwood S, Ell C, Fiocca
Smooth extubation and aggressive prophy- R, Eklund S, et al. Laparoscopic Antireflux sur-
laxis against postoperative nausea and vomiting gery vs esomeprazole treatment for chronic GERD:
the LOTUS randomized clinical trial. JAMA.
2011;305(19):1969–77.
• Avoid retching which may contribute to early 10. Spechler SJ, Hunter JG, Jones KM, Lee R, Smith BR,
failure of the repair. Mashimo H, et al. Randomized trial of medical versus
• Respiratory exercises (e.g., incentive spirom- surgical treatment for refractory heartburn. N Engl J
Med. 2019;381(16):1513–23.
etry), chest physiotherapy. 11. Kim D, Velanovich V. Surgical treatment of GERD:
• Mechanical and chemical prophylaxis for where have we been and where are we going?
venous thromboembolism. Gastroenterol Clin. 2014;43(1):135–45.
Liquid diet for 24 h, upgrade if tolerating to a

minced and moist diet for 4 weeks, then cautious
reintroduction of solids.
Hiatal Hernia: Update
and Technical Aspects
Andrea Zanoni, Alberto Sartori, and Enrico Lauro
Introduction hiatal hernia, leads to the disruption of natural

anti-reflux mechanisms and hernia size is one of
Hiatal hernia is defined as the herniation of the the main determinant of reflux severity [2]. Indeed,
stomach, possibly with other abdominal cavity symptoms of hiatal hernia can be distinguished
elements, through the esophageal hiatus of the dia- into GERD-related and Non-GERD-related.
phragm. The most used classification describes GERD symptoms are described in another chapter.
four types of hernia: type I is the sliding hiatus her- Non-GERD symptoms include all those related to
nia; type II the rolling hernia, where the gastric compression of mediastinal structures and to dam-
fundus herniate, while the gastroesophageal junc- age of herniated organs. A particular case is that of
tion remains in the abdomen; type III the mixed asymptomatic paraesophageal hernias. In those
hernia: with elements of both types I and II her- patients, prophylactic paraesophageal hernia
nias; type IV is characterized by the presence of repair is debated among experts. Although there is
organs other than the stomach in the hernia sac. no consensus, most would agree that very old or
Types II–IV hernias as a group are referred to as debilitated patients should not undergo surgery,
paraesophageal hernias. Type I is the most com- while younger and healthier patients, with a life
mon (95% of the cases), followed by type III, expectancy of at least 10 years, should consider
which comprises almost all paraesophageal her- surgery to prevent both the risk of acute complica-
nias. Type II and IV are rare. Gastric volvulus is tions and potentially progressive symptoms [3].
commonly associated with paraesophageal hiatal We here describe hiatal hernia repair associated
hernias. During sac reduction, the content is also with floppy Nissen fundoplication. This procedure
retracted into the abdomen and the volvulus is appears to be the most effective one and is consid-
automatically derotated. Natural history of hiatal ered the gold standard [4, 5] but it is also associ-
hernias is not really known, but preliminary stud- ated with nonnegligible potential for dysphagia
ies suggest that, like all other types of hernia, they and gas bloat syndrome. Adding a fundoplication
tend to increase in size over time [1]. The anatomic after crural repair is strongly suggested by experts
disruption of the gastroesophageal junction, due to to stabilize the repair and reduce postoperative
GERD; however, this step is not considered strictly
A. Zanoni (*) · E. Lauro necessary in the literature. The use of meshes is
General Surgery Division, Santa Maria del Carmine debated, but it can be useful, if not even necessary,
Hospital, Rovereto, Italy
in some cases of difficult direct repair. Both
e-mail: andrea.zanoni@apss.tn.it
absorbable and nonabsorbable meshes have been
A. Sartori
used. We prefer absorbable meshes, which disap-
U.O. General and Emergency Surgery, San Valentino
Hospital, Montebelluna, Treviso, Italy pear and create a scaffold for tissue repair, reduc-
https://doi.org/10.1007/978-981-19-3755-2_35
230 A. Zanoni et al.
ing if not eliminating the risk of esophageal • laryngitis and laryngospasm.

erosion. This dreaded complication has been • asthma.
instead reported for nonabsorbable meshes. • recurrent aspiration pneumonia.
Moreover, the pressure gradient across the • cardiac conduction defects.
abdominal and thoracic cavities predisposes the • dental erosions and gingivitis.
patient to recurrence. The clinical recurrence rate • symptomatic or complicated paraesophageal
is much lower than radiographic recurrence hernia.
(assessed by a barium esophagram). Most
patients with radiographic recurrence after repair
are asymptomatic. Only a small fraction of Non-GERD Indications
patients will require a re-repair for complications
or intractable symptoms (around 15% of • Emergency repair: acute gastric volvulus,
patients). Since complications are not negligible, uncontrolled bleeding, obstruction, strangula-
meticulous selection of patients, good indication, perforation, or respiratory compromise
tions, and careful application of surgical princi- secondary to a paraesophageal hernia.
ples and techniques are mandatory to increase the • Elective repair: subacute symptoms, like
chance of successful results. In this chapter, we respiratory complications from mechanical
will mainly focus on indications for surgery and compression of the lungs (post-prandial chest
surgical steps, since we strongly believe that fullness, shortness of breath), dysphagia, post-
these are the keys for a successful operation. prandial thoracic pain, anemia or chronic
bleeding, cardiac problems from compression
of the heart.
Indications • Prophylactic repair in asymptomatic patients:
suggested in fit patients.
GERD-Related Esophageal
Indications
Contraindications
• Failed optimal medical management (persis-
tent symptoms on PPI). • Unstable or incurable preexisting
• Noncompliance (unwillingness or intoler- comorbidities.
ance/side effects) with chronic medical • Unable to tolerate general anesthesia.
therapy. • Morbidly obese patients (BMI >40 kg/m2)
• High volume/severe regurgitation (liquid or (relative, consider bariatric surgery).
solid) and regurgitation as main complaint. • Advanced age (relative).
• Nonacid reflux. • Coagulopathy (relative).
• Severe esophagitis by endoscopy (Los Angeles • Previous extensive abdominal surgery
C & D) and stricture. (relative).
• Barrett’s columnar-lined epithelium (short
Barrett & without severe dysplasia or
carcinoma). Preoperative Workup
• EGD (to detect esophagitis, hiatal hernia,

GERD-Related Extra-esophageal Barrett’s esophagus, or neoplastic lesions).
Indications (If Condition Is Surely • 24 hours pH-impedence test (only in case of
Related to Reflux) GERD symptoms)
• Barium swallow (to measure the size of hiatal
• hoarseness. hernia, to describe if hernia is stable or inter-
• cough. mittent, to detect and describe the degree of
• globus (lump sensation in the throat). regurgitation of contrast medium).
Hiatal Hernia: Update and Technical Aspects 231
• Manometry (to rule out dismotility, like

achalasia).
• CT scan (to study the anatomy of esophago-
gastric junction-EGJ region and rule out
extrinsic compression of the esophagus and
EGJ).
Laparoscopic Instrumentations
• Laparoscopic gauzes and epinephrine (water-

diluted epinephrine-soaked gauzes can help
stop minimal bleeding).
• Veress needle.
• Three 10–12 mm trocars and two 5 mm
trocars. Fig. 1 Port placement
• Bipolar laparoscopic forceps.
• Energy device: ultrasonic or radiofrequency The distance from midline increases in
dissector. patients with higher BMI.
• Laparoscopic curved scissor. –– Port B (10 mm): surgeon’s right-hand working
• Laparoscopic needle holder. port. Placed on the midclavicular line on the
• 2/0 or 0 nonabsorbable braided suture. left side of the patient, immediately below the
• Endoscopic liver retractor and table-mounted costal margin.
retractor holder. –– Port C (5 mm): surgeon’s left-hand working
• Endoclip applier. port. Below the xiphoid process, slightly
• Atraumatic graspers. higher than port B to better access the medias-
• Cotton surgical tape or Penrose drain. tinum. It is preferable to place this port imme-
• Suction/irrigation device. diately left to the falciform ligament to avoid
• Mesh (absorbable or nonabsorbable). interference during instrument exchanges.
–– Port D (5 mm): first assistant port, placed just
below the left costal margin.
Patient Setup and Position –– Port E (5–12 mm): liver retractor port, placed
below the right costal margin.
–– Standard supine position.
–– Split legs “French Position” (suggested, but
optional) or Standard Supine “American Surgical Technique
Position.”
–– Reverse Trendelenburg position. There are several controversies in the surgical
–– Surgeon between patient’s legs or on the repair of a hiatal hernia but some steps are still
patient’s left side. critical for a successful outcome [3].
Trocars Placement (Fig.1) Essential Steps
–– Port A (10 mm): camera port. Initial access is Dissection of hiatus and sac excision.
gained with an open or closed technique Mobilization of esophagus.
approximately 12–14 cm from the xiphoid Mobilization of gastric fundus and short gastric
process, slightly on the left side of the patient. vessel division.
Crural closure with or without mesh age of the crus should be preserved to provide
reinforcement. some support at the time of crural closure.
Floppy Nissen fundoplication. –– Care should be taken to identify and preserve
Control endoscopy (optional). the anterior and posterior vagus nerves,
remembering that the anterior one traverses
along the anterior esophagus from the left of
Description of the Technique the patient, while the posterior one comes
from the right.
Dissection of Hiatus and Sac Excision –– When the sac and its contents are successfully
reduced, a retroesophageal passage is created
–– After trocars placement, abdominal explora- and a cotton surgical tape or Penrose drain is
tion is carried out and liver is retracted, expos- placed around the esophagus, to provide atrau-
ing the hiatus (Fig. 2). matic retraction by the first assistant for safe
–– The procedure starts with the division of the esophageal dissection (Fig. 3).
pars flaccida and condensa of lesser omentum,
possibly preserving the left vagal branch of Mobilization of Esophagus
the anterior vagus, with right crus –– Retracting the surgical tape inferiorly, dissec-
identification. tion around the esophagus is carried out. Since
–– Then, the right crus is dissected starting at the it is a mainly an avascular plane, blunt dissec-
11 o’clock position, bluntly entering the medi- tion should be preferred as much as possible,
astinum. A gentle reduction of the hernia con- with the exception of a few esophageal aortic
tents is initially attempted, but only for the branches that need division with the energy
part that can be easily reduced: the critical device.
step is to reduce the entire sac into the abdo- –– The esophagus should be freed and mobilized
men, which will bring together the content. extensively up to the inferior pulmonary veins.
Sac dissection facilitates reduction of the her- It is important to gain at least 3 cm of intra-
nia, protects the esophagus from iatrogenic abdominal esophagus, which should be mobile
damage, and decreases early recurrence. and should remain in the abdomen without
–– The sac dissection is bluntly carried out with tension.
the assistant grasping the sac margin and pull- –– Important structures surround the esophagus
ing it downwards. It is important to completely in the mediastinum, care should be taken to
dissect and reduce the sac into the abdomen, identify and preserve both vagus nerves and
possibly without tearing it. The dissection will avoid injury of pleura, pericardium, inferior
need to go down to the decussation of the cru- pulmonary veins, and aorta. Injury of the
ral fibers of the left crus. The peritoneal cover- pleura during mediastinal dissection is fre-
Fig. 3 A Retro-esophageal window is created to facilitate

Fig. 2 Large Hiatal Hernia at diagnostic laparoscopy dissection and mobilization of the lower esophagus
quent in big hernias, nevertheless it does not rural Closure with or Without Mesh
C
require to be repaired to avoid causing tension Reinforcement
pneumothorax. At the end of the procedure, –– The crus should be closed posteriorly, with
the Valsalva maneuver at extubation will evac- possible addition of anterior closure in case of
uate CO2. Rarely, in case of severe respiratory wide hiatus.
distress, a chest drain can be placed. –– The crus should be repaired with 0 or 2/0
braided nonabsorbable sutures. Normally a
obilization of Gastric Fundus
M direct closure is sufficient to repair the defect.
and Short Gastric Vessels Division Nevertheless, in case of a huge hiatal defect
–– When the esophagus is well mobilized, the (normally more than 5 cm) or weak and frag-
gastric fundus mobilization begins. The key to ile crural muscles, a mesh can be placed onlay
successful floppy Nissen consists in the divi- after direct repair. “Figure of 8” sutures or
sion of the short gastric vessels necessary for simple interrupted sutures are the best options
the fundoplication, avoiding excessive gas- for crural repair (Fig. 5). Both absorbable and
trolysis on the greater curvature, which might nonabsorbable meshes have been used. We
be involved in “gas bloat syndrome.” prefer absorbable meshes, which disappear
–– The first assistant grasps the apex of the gas- and create a scaffold for tissue repair, reducing
trosplenic ligament and the surgeon the ante- if not eliminating the risk of esophageal ero-
rior wall of the stomach for countertraction. sion (Fig. 6). This dreaded complication has
Then the lesser sac is entered approximately been instead reported for nonabsorbable
above the lower limit of the spleen, used as a meshes. The mesh is fixed laterally to the pil-
caudal landmark. The dissection proceeds lars with single stitches or absorbable tacks,
upwards close to the gastric wall, avoiding avoiding to place tacks on the anterior and
inadvertent thermal injuries to the stomach, up
to the left crus (Fig. 4).
–– The fundus must be freed completely on the
posterior wall, dividing all short gastric ves-
sels. High Frequency bipolar or ultrasonic dis-
sectors normally provide good hemostasis
without the need for clipping.
–– Mobilization of the gastric fundus ends the
first part of the procedure. Correct mobiliza-
tion of esophagus and gastric fundus is
mandatory to obtain an adequate retroesopha-
geal window for a floppy Nissen. Fig. 5 Crural Closure using breaded nonabsorbable
suture
Fig. 4 Gastric Fundus mobilization along the greater Fig. 6 Mesh used for crural reinforcement (optional)
curvature
posterior hiatus, for the high risk of damage to

pericardium and aorta, respectively.
–– The crural closure should neither strangulate
nor shred the muscle.
–– Once the hiatus is repaired, the esophagus
should comfortably occupy the defect, with-
out being angulated or compressed. The clo-
sure should permit easy passage of a 5 mm-tip
instrument.
Fig. 7 The so-called shoeshine maneuver to confirm that
loppy Nissen Fundoplication
F the fundus is sliding loose around the esophagus
–– The last step of the procedure consists of the
construction of a floppy fundoplication. This
is 360° fundoplication positioned around the
distal esophagus and esophagogastric junction
(at the level of the Z line). It must be short
(2 cm long) and tension-free.
–– The reduced sac should be excised in order to
have a more clean gastric wall to properly per-
form a correct fundoplication.
–– The stomach is replaced in anatomical posi-
tion and the assistant retracts the esophagus
Fig. 8 A floppy fundoplication is made
with the surgical cotton tape to expose the ret-
roesophageal window and the posterior wall
of the stomach.
–– The surgeon brings the posterior fundus
through the retroesophageal window. Then the
so-called shoeshine maneuver is used to con-
firm that the fundus remains comfortably in
position and is not retracted to the left of the
patient (Fig. 7).
–– The fundoplication is created with 2 or 3
interrupted nonabsorbable braided sutures (0
or 2/0). One or more sutures can incorporate Fig. 9 To avoid slippage, additional suture may be useful
the anterior esophageal wall. Nonetheless, to fix the wrap inferiorly
we prefer to avoid including the esophagus,
obtaining a more floppy wrap, and avoid above the fundoplication if needed. Posterior
damaging the anterior vagus nerve (Fig. 8). or anterior gastropexy sutures can be further
We prefer fixing the fundoplication with a added.
lateral suture from the inferior left border of –– Intraoperative control endoscopy can be per-
the wrap to the anterolateral esophageal wall formed to confirm correct position and patency
at the level of the dissected phrenoesopha- of the fundoplication and absence of twisting.
geal membrane, in order to avoid telescoping –– No drain is normally necessary. The trocars
or slippage of the wrap (Fig. 9). Other sutures are removed and the incisions are closed in
can be added on the right side or cranially standard fashion.
Postoperative Care and Follow-Up References
–– Upper GI Gastrografin study [1] on the first 1. Abdelmoaty W, Dunst C, Fletcher R, et al. The
development and natural history of hiatal hernias: a
postoperative day is possible but not study using sequential barium upper gastrointestinal
mandatory. series. Ann Surg. 2020;275(3):534–8. https://doi.
–– Clear liquids are allowed on the first postop- org/10.1097/SLA.0000000000004140.
erative day (POD1). 2. Jones MP, Sloan SS, Rabine JC, Ebert CC, Huang
CF, Kahrilas PJ. Hiatal hernia size is the dominant
–– Soft mashed diet is started on POD2 and it is determinant of esophagitis presence and severity in
suggested until POD7. gastroesophageal reflux disease. Am J Gastroenterol.
–– Soft fractionated diet is started on POD8 and 2001;96(6):1711–7.
suggested for 4–8 weeks, followed by return 3. Bonrath EM, Grantcharov TP. Contemporary man-
agement of paraesophaegeal hernias: establish-
to regular diet. ing a European expert consensus. Surg Endosc.
–– Postoperative dysphagia and delayed gastric 2015;29(8):2180–95.
emptying are common, but patients should be 4. Guidelines for surgical treatment of gastroesopha-
instructed that these symptoms are typically self- geal reflux disease (GERD). Society of American
Gastrointestinal and Endoscopic Surgeons
limiting and should disappear approximately 2 (SAGES). https://www.sages.org/publications/
months after surgery. guidelines/guidelines-f or-s urgical-t reatment-o f-
–– Antiemetics are given at scheduled times for gastroesophageal-reflux-disease-gerd/.
the first 24 h, to avoid early retching and early 5. Guidelines for the management of hiatal her-
nia. Society of American Gastrointestinal and
recurrence, and then on demand. Endoscopic Surgeons (SAGES). https://www.sages.
–– PPI are normally used in the first 15–30 days org/publications/guidelines/guidelines-f or-t he-
and then suspended. management-of-hiatal-hernia/.
–– Discharged with prescription for antiemetics.
–– Follow-up at 1 week with clinical evaluation,
then at 1 month with a barium swallow study.
We normally suggest further clinical evaluation
at 6 months after surgery and then on demand.
Esophageal Cysts
Aung Myint Oo
Introduction by dysphagia. Some other symptoms include

epigastric discomfort, vomiting, stridor, cough,
Esophageal cysts are rare congenital anomalies bleeding, and hematemesis. Presentation
of gastrointestinal tract first described by Blasius of hematemesis is associated with the pres-
in 1711. In 1881, Roth also described esophageal ence of gastric epithelium in the cyst. Rarely
cysts and there are two categories namely simple they can present as malignant transformation.
epithelial lined cysts and esophageal duplication Sometimes esophageal cysts are diagnosed
cysts. Esophageal duplication cysts are embryo- incidentally.
logic duplication of part of the esophageal
mucosa and submucosa without epithelial dupli-
cation. The prevalence of esophageal duplication Diagnosis
cysts is 0.0122% and accounts for 10–15% of
duplication cysts in the gastrointestinal tract [1]. Diagnosis can be made mainly by computed
Esophageal cysts and duplications usually do not tomography (CT) and endoscopic ultrasound
have communication with the lumen and they can (EUS). Fluid-filled cystic lesion arising from
be found in the neck, chest, and abdomen. Most esophagus in CT scan usually represents the diag-
of the esophageal duplication cysts (two-thirds) nosis of esophageal cysts which can be confirmed
are found in the lower esophagus in the right pos- by EUS. On EUS examination, the duplication
teroinferior mediastinum while 1/3 in the upper/ cysts appear as periesophageal homogenous
middle third of esophagus and sometimes lesions hypoechoic mass with multilayered wall and well-
can be found in the intra-abdominal esophagus. defined margins or sometimes as anechoic cysts
due to a considerable amount of central fluid. EUS-
guided FNA aspiration is associated with risks of
Presentation infection as high as 14% and thus EUS FNA/
FNAB with appropriate antibiotics cover should be
67% of esophageal duplication cysts in adults considered only when the diagnosis is in doubt or
can be presented with symptoms and chest any suspicious features of malignant transforma-
pain is the most common symptom followed tion. Esophageal cysts/duplication cysts are usually
found as submucosal lesions during upper gastro-
A. M. Oo (*)
Upper Gastrointestinal, Bariatric and Metabolic
Surgery, Department of General Surgery, Tan Tock
Seng Hospital, Singapore, Singapore
e-mail: myint_oo_aung@ttsh.com.sg
https://doi.org/10.1007/978-981-19-3755-2_36
238 A. M. Oo
intestinal endoscopy without involving the mucosa. also be helpful for better postoperative
If there is involvement of mucosa then biopsies can outcomes.
be taken during endoscopy.
OT Setup
Indications and Contraindications
Except for the intra-abdominal esophageal cysts
Surgical removal is the treatment of choice for which can be approached by laparoscopy most of
symptomatic patients. While asymptomatic the esophageal cysts are approached by
patients can be opted for surveillance and follow thoracoscopy.
up, surgical removal can also be considered due For laparoscopic approach, monitor for sur-
to the potential risks of complications including geon and scopist is at the eye level on the patient’s
mucosal ulceration, bleeding, perforation, and left side and the monitor for the assistant on the
rarely the malignant transformation. Simple cysts right side. The energy devices are set up at the
can be enucleated, the duplication cysts are patient’s foot, suction and irrigation at the
excised. With the advancement in minimally patient’s right near the head (Fig. 1).
invasive surgeries including endoscopic interven- For thoracoscopic approach with left lateral
tion, the outcomes are quite satisfactory and position, monitor for the surgeon and scopist at
excellent. As surgical intervention is associated the eye level in front of the patient (surgeon and
with long-term complications such as heartburn, scopist positioned at the patient’s back), while
reflux esophagitis, balancing the risks and bene- the assistant position at the front with the monitor
fits of surgical intervention is very important and facing him from the patient’s back.
needed to be carefully considered and counseled For thoracoscopic approach with semi-prone/
in asymptomatic patients without worrisome fea- prone position, monitor for the surgeon and sco-
tures. Endoscopic intervention by draining the pist at the eye level facing the patient’s back (sur-
cyst into the esophageal lumen or submucosal geon and scopist position at the patient’s front)
tunneling dissection can be considered for suit- while the assistant stands from the patient’s back
able patients including those with high risk for with monitor at the eye level from patient’s front.
surgery.
Pre-op Assessment
Pre-op assessment is the same for those who need

esophageal surgery. Those patients who need
transthoracic approach will need their pulmonary
function to be evaluated. Patient’s fitness for gen-
eral anesthesia and surgery will also be assessed
preoperatively by anesthesiologists and optimi-
zation of comorbidities by respective specialists
accordingly. Pre-op optimization of nutrition and
rehabilitation with pulmonary physiotherapy will Fig. 1 OT setup for laparoscopic approach
Esophageal Cysts 239
Instrumentations
The following instruments are mostly used in the

procedures.
30° telescope with camera system.

Short bowel grasper.
Mary land grasper.
Hook.
Energy device (ultrasonic dissector or advanced
bipolar dissector).
Laparoscopic needle holder.
Scissors.
Lung retractor.
Liver retractor.
Fig. 2 Port positions for laparoscopic procedure

Patient’s Position
For laparoscopic approach, patient is put in the

supine position with reverse Trendelenburg and
right side down position (Fig. 2).
For thoracoscopic left approach, patient is put in
the left lateral position with both ventral and dorsal
support with operating table bent at 30° at the level
of pelvis to open the rib spaces as well as in the best
position if open conversion is needed (Fig. 3).
For thoracoscopic semi-prone or prone
approach, the support is put under the abdomen
as well as at the level of the shoulder blade in to
widen the rib spaces (Fig. 4a).
Regardless of the position, it is important to Fig. 3 Port positions for thoracoscopic procedure in left
make sure that patient is well supported securely, lateral position
and all the presser points are supported with soft
pads/cushions.
a b
Fig. 4 (a) Patient is prone/semi prone position. (b) Ports positions in semi prone/prone position
240 A. M. Oo
Surgical Technique
Thoracoscopic Procedures
for Thoracic Esophageal Cyst
After general anesthesia with one lung ventila-

tion either using double lumen tubes or bronchial
blocker, patient is positioned in left lateral posi-
tion or semi-prone/prone position as per sur-
geon’s preference. For left lateral position,10 mm
camera port is inserted at seventh or eighth inter-
costal space anterior axillary line. Working ports
for surgeons are 1 × 10 × 12 mm port at seventh
or eighth intercostal space at posterior axillary
line and 1 × 5 mm at third or fourth intercostal
space mid axillary line. One assistant port either
5 or 10 mm depending on the availability of the
lung retractor is inserted at fifth intercostal place Fig. 5 Reduced Ports(three ports) position for laparo-
ventral to the anterior axillary line (Fig. 3). scopic procedure
For semi-prone or prone position,
1 × 10 × 12 mm camera port at seventh intercos-
tal space posterior axillary line. 2 × 5 mm sur- Enucleation/Resection of Esophageal
geon ports one at third or fourth intercostal space Cysts
posterior axillary line and one just below the tip
of the scapula. 1 × 5 mm assistant port at eighth After ports are inserted, the esophageal cyst is
or ninth intercostal space along the scapula line identified and mobilized carefully from mediasti-
(Fig. 4b). nal pleura by dissecting around the cyst using the
energy device and hook diathermy. Dissection of
the hiatus will be needed for intra-abdominal
aparoscopic Surgery for Intra-
L esophageal cysts. After dissecting the longitudi-
abdominal Esophageal Cyst nal and circular fibers of the esophageal wall, the
enucleation/resection of the cyst is performed by
After general anesthesia, patient is positioned in dissecting the cyst completely off from the
the supine position, 10 mm camera port is mucosa wall without injuring the cyst wall and
inserted infra umbilicus, the 1 × 10 mm working mucosa. Care must also be taken not to injure the
port is inserted at right hypochondrium along the nerves during the dissection. After completion of
lateral border of rectus abdominus muscle and the enucleation/resection of the cyst, on-table
just lateral and superior to the camera port. endoscopic examination with air sufflation under
1 × 5 mm working port is inserted just 3–4 finger water is done to check for any mucosal injury and
breadth above and slightly lateral to the 10 mm repair with 3/0 absorbable suture if needed. The
working port (Fig. 5) If needed the additional dissected muscle fibers and pleura are then closed
one or two assistant 5 mm ports can be inserted with 3/0 absorbable sutures to reinforce the
in the left upper abdomen (Fig. 2). The Nathanson defect as well as to prevent the pseudodiverticu-
liver retractor is inserted from the small 5 mm lum formation. After checking the hemostasis
incision at the epigastrium just below the and suctioning of the fluid, the excised cyst is put
xiphisternum. into the retrieving bag and extracted by enlarging
Esophageal Cysts 241
the camera port wound at the end of the surgery. • Bleeding—endoscopic hemostasis if intralu-
For thoracoscopic procedure, one underwater minal, or surgical hemostasis if bleeding did
seal chest tube drain is placed via one of the tho- not stop spontaneously.
racoscopic port sites. The chest drain is kept for 1 • Wound infection—less with the minimally
or 2 days for post-op pneumothorax. However, invasive approach compared with open
drain is usually not needed for laparoscopic enu- approach.
cleation/resection of abdominal esophageal cyst.
Post-op Care
Postoperatively patients will be monitored in the
Even though complications are rare, the possible ward. The chest tube if inserted can be removed
complications and their prevention/management in the next 1 or 2 days if there is no pneumotho-
include. rax. Patient can start oral liquid the next day fol-
lowed by diet if tolerating well and most of the
• Pneumonia—managed by pre- and post-op patients can be discharged on POD (Post-
chest physiotherapy with incentive spirometry. operative Day) 2 or 3. Chest physiotherapy with
• Air leak and pneumothorax—may need a incentive spirometry and ambulatory physiother-
chest tube. apy can start on POD 1. After discharge, the
• Esophageal injury and leak—adequate drainage patient is followed up in outpatient clinic.
of the collection and nasogastric tube (NGT)
decompression, application of endoscopic over
the scope clip/esophageal stent, or rarely the sur- Reference
gical intervention.
• Injuries to vagus nerves and/or phrenic 1. Olajide AR, Yisau A, et al. Gastrointestinal duplica-
tions: experience in seven children and a review of the
nerve—careful dissection during the excision/ literature. Saudi J Gastroenterol. 2010;16(2):105–9.
enucleation is very important to prevent inju- https://doi.org/10.4103/1319-3767.61237.
ries to the nerves.
• Formation of pseudodiverticulum—it is
important to suture the muscle layers to pre-
vent pseudodiverticulum formation.
McKeown Esophagectomy
Koji Kono
Introduction esophagectomy (MIE) in 1992 [10], MIE has

become one of the standard surgical approach for
Esophageal cancer is the sixth most frequent esophageal cancer. A randomized trial of MIE
cause of cancer death worldwide and affects compared with open esophagectomy showed a
more than 450,000 people all over the world [1]. lower incidence of pulmonary infections, a
Most patients with esophageal cancer in Asian shorter hospital stay, and better short-term qual-
countries such as Japan and China have squa- ity of life than did open esophagectomy, with no
mous cell carcinoma (SCC), while most of those compromise in the quality of the resected speci-
in Western countries have adenocarcinoma [2, 3]. men [11]. Moreover, treatment in high-volume
In particular, the incidence of esophageal adeno- centers with experienced surgeons and the avail-
carcinoma in the USA and the UK is rapidly ability of critical-care support is associated with
increasing, in which the age-adjusted incidence improved outcomes [12].
has risen by 39·6% for men and 37·5% for women
every 5 years in the UK [3]. Despite improve-
ments in surgical techniques and perioperative McKeown Esophagectomy
management [4, 5] and surgery combined with
chemotherapy and/or radiotherapy [6, 7], the The common surgical approaches to curatively
prognosis of esophageal cancer at advanced stage resect esophageal cancer include trans-hiatal,
remains poor with 30–40% in a 5-year survival Ivor Lewis, and McKeown (three incision)
globally [8] and the 5-year survival rate for the esophagogastrectomy [13]. McKeown esopha-
patients receiving esophagectomy in Japan was gectomy is defined as consisting of thoracic
55.5% [9]. esophageal mobilization with lymph node dissec-
It is generally accepted that conventional open tion (thoracoscopic or open), abdominal explora-
surgical procedures for esophageal cancer are tion (laparoscopic or open), and stomach
traumatic and invasive, despite continuous mobilization with lymph node dissection, and
advances in perioperative management and surgi- subsequently left cervical incision for anastomo-
cal techniques. Since Cuschieri et al. reported sis. Potential advantages of the McKeown
thoracoscopic surgery in minimally invasive approach compared to the Ivor Lewis include less
incidence of local recurrence, applicable to the
K. Kono (*) tumors at or above the level of carina, and anasto-
Department of Gastrointestinal Tract Surgery, mosis in neck easier to manage if anastomotic
Fukushima Medical University, Fukushima, Japan leak occurs [13]. The issue of two-field (thoracic
e-mail: kojikono@fmu.ac.jp

https://doi.org/10.1007/978-981-19-3755-2_37
244 K. Kono
+ abdomen) vs. three-field (thoracic + abdomen Position/Port Position

+ neck) lymph node dissection is still debatable.
McKeown esophagectomy is appropriate for Raise both hands, and take a prone position with
all patients with Siewert type I and II patients, as the face fixed by Prone View® and the trunk fixed
well as all patients with tumor above the gastro- by a spine surgery operation frame (Spine Table)
esophageal junction, up to the level of the clavi- (Fig. 1). By using the position, interference
cle. Most importantly, Ivor Lewis should not be between the forceps and the operating table is
applied to tumors at or above the level of carina prevented. After intubation of a single lumen spi-
due to the risk of a positive esophageal surgical ral tracheal tube, a blocker is placed in the right
margin. main bronchus for left single lung ventilation in
order to make surgical field stable. Alternatively,
both lung ventilation with artificial pneumotho-
Indications for McKeown rax also can be possible.
Esophagectomy Port placement starts with four ports as shown
in Fig. 2 and 6 mmHg pressure under artificial
• Carcinoma of the upper, middle, and lower pneumothorax. First, a 12 mm trocar is inserted
third of the esophagus, especially applicable into fifth intercostal space (ICS), while observing
to the tumors above the level of carina. with a 0° rigid endoscope, and the pleural inci-
• T1a carcinoma not amenable to endoscopic sion is safely observed under direct vision to pre-
resection, T1b, T2, T3, and T4a. vent lung injury. After confirming the proper
• Salvage esophagectomy after definitive insertion of the port into the chest cavity, pneu-
chemoradiation. mothorax is initiated and a complete collapse of
• End-stage benign strictures of the esophagus the right lung is obtained. Thereafter, the endo-
are not amenable to trans-oral dilations (caus- scope is changed to a 30° rigid endoscope to per-
tic injury, peptic structures). form intrathoracic operation. Next, insert a
12 mm port into the ninth ICS as a camera port,
and insert a 5 mm port into the seventh ICS and a
Contraindications 5 mm port into the third ICS. The operator uses
• Tracheobronchial, mediastinal, and intra-

abdominal structures invasion (T4b).
• Stage IVb disease.
• Advanced physiologic age and frailty.
• Prohibitive comorbidities.
OT Setup
Device
The basic surgical device uses a spatula-type

monopolar electric scalpel and LigaSure™ Fig. 1 Position of the patients. Raise both hands, and take
a prone position with the face fixed by Prone View® and
Maryland 37, and a microline scissors for manip- the trunk fixed by a spine surgery operation frame (Spine
ulating around the recurrent laryngeal nerve. Table)
McKeown Esophagectomy 245
the fifth and seventh ICS port, and the assistant Description of the Technique
uses the third ICS port (Figs. 2 and 3).
First, a 12 mm trocar is inserted into V inter- Dissection of the Azygos Vein
costal space (ICS), while observing with a An incision is made in the mediastinum pleura
0°degree rigid endoscope, and the pleural inci- and the azygos vein is isolated with preservation
sion is observed under direct vision to prevent of the right bronchial artery at the backside of the
lung injury. After confirming the proper inser- azygos vein. The azygos vein is dissected with
tion of the port into the chest cavity, pneumo- Powered ECHELON FLEX® 7 (Fig. 4) and con-
thorax is initiated and a complete collapse of firm the preservation of the right bronchial artery
the right lung is obtained. Thereafter, the endo- (Fig. 5). At this point, the camera is moved to the
scope is changed to a 30° rigid endoscope to fifth ICS port, and the Powered ECHELON is
perform intrathoracic operation. Next, insert a inserted from the ninth ICS to adjust the axis of
12 mm port into the ninth ICS as a camera port, the device. The dorsal stump of the azygos vein is
and insert a 5 mm port into the seventh ICS and grasped by the end loop PDSII® and lifted out-
a 5 mm port into the third ICS. The operator ward to ensure a visual field near the root of the
uses the fifth and seventh intercostal space right bronchial artery.
port, and the assistant uses the third intercostal
space port.
Insert a 12 mm port into the ninth intercostal
space as a camera port and the operator uses the
5th (12 mm) and 7th (5 mm) intercostal space
port, and the assistant uses the third intercostal
space port (5 mm).
Fig. 4 Azygos vein transection
Fig. 2 Port insertion
Fig. 3 Port Fig. 5 Preservation of the right bronchial artery

246 K. Kono
issection of Lymph Node Along

D end loop PDSII® or clip (Fig. 7). On the oral side,
the Rt-recurrent Nerve the thoracic duct was attached to the esophagus.
The mediastinal pleura is dissected along the The mid-thoracic and upper thoracic esophagus
right vagus nerve until the right subclavian artery, are separated from the Aortic Arch and the left
and the pleura is dissected posteriorly on the right pleura. In some cases depending on the T- or
subclavian artery to expose the front surface of N-factors, we are preserving the thoracic duct.
the right subclavian artery (Fig. 6). Next, along
the right wall of the trachea, the tissue containing issection of Subcarinal Lymph Node
D
the right recurrent laryngeal nerve is mobilized. The lower right pulmonary ligament is dissected,
At this time, the blood vessel plexus on the side and the pleura, the pericardium, and the right pul-
wall of the trachea should be preserved to main- monary vein are identified. The right main bron-
tain the blood flow for the trachea. This lym- chus is identified near the right hilum, lymph node
phatic tissue is sharply and bluntly dissected with along Rt-main bronchus, and subcarinal lymph
a Microline® scissor to identify and preserve the node are dissected at the tracheal bifurcation
right recurrent laryngeal nerve and to dissect the (Fig. 8), while preserving lung branches from the
lymph node, which is mainly located on the dor- right vagus nerve. The right vagus nerve is dis-
sal side (Fig. 6). In the area around the Rt-recurrent sected on the peripheral side after the pulmonary
laryngeal nerve, the use of an electric scalpel or a branch to maintain the cough reflux (Fig. 9).
vessel sealer should be avoided. Lymph node dis-
section is performed until the back side of the
right subclavian artery and there is a branch of
the inferior thyroid artery in the area, so it is
essential to prevent bleeding and keep the surgi-
cal site dry.
issection of the Thoracic Duct

D
In the mediastinum, the ventral side of the azygos
vein is mobilized from the Aorta, and the thoracic
duct is identified on the ventral side. The ligation
of the thoracic duct is based on the collective
ligation including the surrounding tissue with the Fig. 7 Dissection of the thoracic duct
Fig. 6 Dissection of lymph node along the Rt-recurrent

nerve Fig. 8 Subcarinal lymph node dissection
Fig. 10 Encircle the upper thoracic esophagus
Fig. 9 Preservation of the pulmonary branch of the

Rt-vagus nerve
issection of the Lymph Node Along

D
Lt-recurrent Nerve
The upper thoracic esophagus is detached from
the left side wall of the trachea and encircles the
esophagus at the height of the Aortic Arch and
Rt-subclavian artery, by guiding with Endomini
Retract®, and stretch the upper thoracic esopha-
gus to upper direction at two positions (Fig. 10).
The surrounding tissue including Lt-recurrent
laryngeal nerve is mobilized from the trachea and Fig. 11 Dissection of lymph node along Lt-recurrent
laryngeal nerve
easily identifies the Lt-recurrent laryngeal nerve.
Then, using a microline scissors, the left recur-
rent laryngeal nerve is exposed, and the lymph By securing the Lt-recurrent laryngeal nerve
nodes along the Lt-recurrent nerve are sharply toward Aortic Arch, and the lymph node sur-
and bluntly dissected (Fig. 11). Thereafter, dis- rounded by the left main trachea, the left pulmo-
sect the esophagus using the Powered ECHELON nary artery wall, the Aortic Arch, and the left
FLEX® GST system (Fig. 12) and pulling up the vagus nerve is dissected. The left bronchial artery
oral side of the esophagus to upper direction, can be identified and it is securely preserved.
lymph node dissection along the Lt-recurrent Care should be taken as damage to the left bron-
nerve is performed until the oral side as much as chial artery can lead to major bleeding.
possible, but the dissection from the mediastinum
side is completed at the site where adipose tissue issection of Lymph Node in the Mid
D
is found on the trachea side (pre-tracheal fat), and Mediastinum
the lymph node dissection along the Lt-recurrent By exposing the left main bronchus, pericardium,
nerve is continued to the subsequent neck proce- and left pulmonary vein, lymph node in the mid
dure. Over-stretch of the recurrent nerve and use mediastinum is dissected and attached to the cau-
of an electric scalpel or a vessel sealer should be dal side of the esophagus (Fig. 13). The left vagus
avoided. nerve is dissected caudally beyond the left main
248 K. Kono
Fig. 14 Collar incision for neck dissection and

anastomosis
eck Lymph Node Dissection

N
Fig. 12 Transection of the upper thoracic esophagus
The neck skin incision is based on a collar inci-
sion (Fig. 14). The sternocleidomastoid muscle
and anterior cervical muscle group are preserved.
Supraclavicular lymph node, lymph node along
carotid sheath, and lymph node along recurrent
laryngeal nerve are dissected on the both left and
right sides. The omohyoid muscle is resected,
and the transverse carotid artery and vein, and
phrenic nerve should be preserved.
Reconstruction
Our department basically uses the retro-sternal
route for reconstruction of the gastric tube, but in
cases where the gastric tube cannot be used for
reconstruction, such as in cases after gastrec-
tomy, reconstruction of the pedicled jejunum
Fig. 13 Dissection of lymph node in the mid mediastinum
with a vascular anastomosis through the anterior
bronchus to preserve the left vagal pulmonary chest wall.
branch. The retro-sternal space is manually separated
from caudal side and thereafter, under visual
ower Mediastinal Lymph Node
L guidance by laparoscopy, the retro-sternal route
Dissection is made. At the same time, blunt dissection is
The pericardium, left lung pleura, diaphragmatic done from the cervical wound and completes the
limb, and inferior vena cava are exposed and retro-sternal route. The gastric tube is covered
lower mediastinal lymph node is dissected. with a sterilized probe cover for ultrasonic
Several esophageal arteries branched from the waves. While paying attention to the direction
descending aorta can be identified and dissected so that the gastric tube does not twist, pull the
with a vessel sealer. silk thread from the cervical wound and raise
the gastric tube. In order to confirm blood sup-
rainage for the Chest Cavity
D ply for the gastric tube, the ICG fluorography is
After washing, confirm hemostasis, insert routinely performed (Fig. 15), and it is impor-
Thoracic drain (24Fr) from the ninth ICS port tant to check if the demarcation line is present
site. or not.
Postoperative Management
It is generally accepted that the McKeown

esophagectomy in high-volume centers with
experienced surgeons and the availability of
critical-care support is associated with improved
outcomes [12].
When necessary, bronchoscopy or a mini-
tracheostomy can be used to ensure adequate
bronchial toilet. Fluid balance and oxygen satura-
tion should be closely monitored and oxygen
supplementation is essential. It is also important
Fig. 15 ICG fluorography of the gastric tube
to provide nutritional support by enteral feeding
through jejunostomy routinely placed at the time
of surgery.
Thrombosis prophylaxis should be performed
by sequential pneumatic compression devices for
the first two postoperative days (POD) and sub-
cutaneous injection of low molecular weight
heparins. Prophylactic antibiotics are given for
24 h.
Physiotherapy with gradual breathing exer-
cises and general condition exercises is per-
formed from the day of surgery to the day of
discharge at least twice a day.
A contrast study to check the integrity of the
anastomosis is routinely performed at 5–7
POD. The chest drain will be removed when the
effluent amounts to less than 200 mL of fluids.
Patients are discharged when they are able to
Fig. 16 Neck anastomosis tolerate the soft diet and the pain is sufficiently
controlled to permit normal mobilization. The
patient is then seen in the outpatient clinic 1
Apply pediatric intestinal forceps to both ends month after discharge.
of the planned cervical esophageal anastomosis,
and perform layer-to layer anastomosis with 4–0
monofilament absorbent thread in the interrupted References
suture fashion (Fig. 16). After completion of the
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reclassification in the marked increase of esopha-
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vical anastomosis leakage occurred. 2005;97(2):142–6.
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MP. Continuing rapid increase in esophageal adeno- Matsubara H, Muro K, et al. Comprehensive regis-
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management of oesophageal cancer. Lancet Oncol. KW, Bonavina L, Rosman C, Garcia JR, et al.
2003;4(8):481–8. Minimally invasive versus open oesophagectomy
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Part IX
Upper Gastrointestinal Surgery: Gastric
Surgery
Gastric Gastrointestinal Stromal
Tumor
Danson Yeo and Jaideep Rao
Introduction 3. Signs of malignancy; irregular margins, cystic

changes, necrosis, and heterogenous
Gastrointestinal stromal tumor (GIST) is the echogenicity.
most common mesenchymal tumor originating in 4. Symptomatic; ulceration and bleeding, gastric
the gastrointestinal tract, originating from the outlet obstruction (large antral GISTs).
interstitial cells of Cajal. GISTs occur most com-
monly in the stomach (60%), followed by the The goal of surgery is R0 surgery (i.e., exci-
small intestine (30%) [1]. sion margins are clear of tumor cells). While lapa-
The standard of care for localized GISTs is roscopic surgery for gastric GISTs resection is
complete surgical resection without dissection of associated with superior postoperative outcomes,
clinically negative lymph nodes [2]. Any GIST is the decision to undertake laparoscopic versus
considered potentially malignant, indications for open surgery should be made at the discretion of
surgery for gastric GISTs are as listed below. For the surgeon. The European Society for Medical
non-gastric GISTs, surgical resection is recom- Oncology (ESMO) guidelines discourage lapa-
mended regardless of tumor size or morphology roscopy for patients with large tumors due to the
[3]. risk of tumor rupture [2], while Otani et al. [4]
suggest 5 cm as the limit for laparoscopic wedge
resection. Intraoperative tumor rupture is associ-
I ndications for Surgery for Gastric ated with a very high risk of peritoneal relapse [5].
GISTs The initial diagnosis of a GIST is usually sug-
gested by endoscopy, endoscopic ultrasound
1. Tumor >2 cm. (EUS), or computed tomography (CT) of the
2. Increase in size on follow-up. abdomen. Preoperative histological diagnosis is
not necessary unless considering neoadjuvant
imatinib therapy [3]. Neoadjuvant imatinib ther-
apy should be considered for localized GISTs
when R0 resection is not feasible or for organ
D. Yeo (*)
Department of General Surgery, Tan Tock Seng preservation [3]. En bloc resection of a GIST that
Hospital, Singapore, Singapore has invaded surrounding organs may be neces-
e-mail: danson_xw_yeo@ttsh.com.sg sary to achieve negative margins and to avoid
J. Rao tumor rupture [6]. The principles of surgery for
Mount Elizabeth Novena Hospital, GIST are negative margins, and resection without
Singapore, Singapore rupture of the tumor.
https://doi.org/10.1007/978-981-19-3755-2_38
254 D. Yeo and J. Rao
Surgical Technique An extraction bag is recommended for retrieval

of the specimen.
Instruments For tumors in the posterior gastric wall, the
• 12 mm ports, 5 mm ports greater omentum may need to be incised in the
• Nathanson retractor (for proximal gastric avascular portion away from the gastroepiploic
GISTs if liver retraction is required. Alternative arcade in order to enter the lesser sac to reach the
methods of liver retraction may be used). tumor.
• 10 mm 30° laparoscope For tumors near the greater or lesser curve, the
• Advanced energy device—author preference omentum and feeding vessels will need to be ligated
is the Harmonic 1000I. and dissected free in order to perform a wedge
• Atraumatic graspers. resection. This is best done with an energy device.
• Clip applicator. The most challenging gastric GIST surgeries
• Suction/irrigation device. are for endophytic tumors, or tumors located in
• Laparoscopic stapler. the fundus, lesser curve, and the antrum.
perating Room Setup and Patient

O ndophytic Gastric GIST on the
E
Position Anterior Gastric Wall
The patient is placed in the supine position with Endophytic Tumors Located on the Anterior
both arms out and a footboard. The laparoscopic Gastric Wall (Fig. 1)
stack is placed on the patient’s left, the machines
for the energy devices are placed at the patient’s • An incision is made on the anterior gastric
feet, and the suction machines are placed on the wall adjacent to the tumor.
patient’s right. • The tumor is then everted through the gastros-
The main surgeon stands on the patient’s right tomy and lifted anteriorly (Fig. 2).
along with the camera assistant, while the first • Lift both edges of the gastrostomy and staple
assistant stands on the patient’s left. across, resecting the tumor and stapling close
After the subumbilical port is placed, the the gastrostomy at the same time. Alternatively,
abdominal cavity is inspected for evidence of the tumor can be excised with a stapler and the
peritoneal metastasis. Pneumoperitoneum is gastrostomy subsequently closed with sutures.
maintained at 12 mmHg. Location of the ports
depends on the location of the tumor, but is gen-
erally similar to that used in laparoscopic
gastrectomy.
Operative Steps
Stapled wedge resection can be easily per-

formed for most anterior wall gastric GISTs.
Tumor rupture must be avoided at all cost. The
tumor should be handled gently if at all, while
and the surrounding tissues can be sutured or
handled for traction. To avoid stenosis, the
tumor should be elevated and the stapler fired
perpendicular to the long axis of the stomach. Fig. 1 Endophytic GIST on the anterior gastric wall
Gastric Gastrointestinal Stromal Tumor 255
Fig. 2 Eversion of tumor through an adjacent

gastrostomy
Fig. 4 Posterior wall tumor lifted through a gastrostomy
on the anterior wall
musculature of the antrum, making it less

mobile.
• Anterior wall tumors may be excised with an
energy source, such as harmonic, and the gastros-
tomy closed transversely to prevent strictures. A
gastrojejunostomy can be performed if there is
concern of stenosis of the antrum/pylorus after
excision.
• In cases of large antral GISTs, it may not be
possible to perform a wedge resection. A distal
gastrectomy may be required to achieve nega-
tive resection margins.
Fig. 3 Anterior gastrostomy overlying the tumor

Fundal/Lesser Curve/
Cardioesophageal Junction (CEJ)
ndophytic Gastric GIST on the
E GISTs
Posterior Gastric Wall
• Resection of a fundal or lesser curve tumor
• An incision is made on the anterior gastric should be performed over a bougie or gastro-
wall overlying the tumor (Fig. 3). scope to ensure that the CEJ is not narrowed.
• The posterior wall tumor is lifted up through • Intragastric resection may be performed for
the gastrostomy and resected with a stapler tumors located in the posterior wall near the
(Fig. 4). CEJ, whereby laparoscopic ports are placed
• The anterior wall gastrostomy is closed with a through the anterior gastric wall into the
stapler or with sutures. gastric lumen, and stapler resection is
performed.
Other methods such as endoscopic submuco-

Antral GISTs sal dissection have been described. However,
enucleation of GISTs is not considered standard
• Stapled wedge resection of broad antral tumors treatment as GISTs do not form a true capsule,
may be difficult to perform due to the thickened originates from the muscle layer (unlike early
256 D. Yeo and J. Rao
gastric cancer), and disruption of the pseudocap- 2. Casali PG, Abecassis N, Aro HT, et al. Gastrointestinal
stromal tumours: ESMO-EURACAN clinical practice
sule and perforation of the gastric wall may hap- guidelines for diagnosis, treatment and follow-up.
pen simultaneously resulting in peritoneal Ann Oncol. 2018;29(Suppl 4):iv267–iv78.
dissemination [7]. 3. Koo DH, Ryu MH, Kim KM, et al. Asian consen-
sus guidelines for the diagnosis and management of
gastrointestinal stromal tumor. Cancer Res Treat.
2016;48(4):1155–66.
Postoperative Management 4. Otani Y, Furukawa T, Yoshida M, et al. Operative indi-
cations for relatively small (2-5 cm) gastrointestinal
Margin status may not be a significant prognos- stromal tumor of the stomach based on analysis of 60
operated cases. Surgery. 2006;139(4):484–92.
tic factor for GIST recurrence [8]. In cases 5. Hohenberger P, Ronellenfitsch U, Oladeji O, et al.
where the resection margin has microscopic Pattern of recurrence in patients with ruptured pri-
tumor cells (R1), postoperative imatinib therapy mary gastrointestinal stromal tumour. Br J Surg.
is recommended when the malignant potential 2010;97(12):1854–9.
6. Gold JS, Dematteo RP. Combined surgical and molec-
is high (based on size and mitotic index). ular therapy: the gastrointestinal stromal tumor model.
Routine surveillance can be performed for low- Ann Surg. 2006;244(2):176–84.
risk GISTs [3]. 7. Kong SH, Yang HK. Surgical treatment of gastric
gastrointestinal stromal tumor. J Gastric Cancer.
2013;13(1):3–18.
8. McCarter MD, Antonescu CR, Ballman KV, et al.
References Microscopically positive margins for primary gastro-
intestinal stromal tumors: analysis of risk factors and
1. Soreide K, Sandvik OM, Soreide JA, Giljaca V, tumor recurrence. J Am Coll Surg. 2012;215(1):53–9.
Jureckova A, Bulusu VR. Global epidemiology of discussion 59–60
gastrointestinal stromal tumours (GIST): a systematic
review of population-based cohort studies. Cancer
Epidemiol. 2016;40:39–46.
Gastric Carcinoma: Subtotal
and Total Gastrectomy
Danson Yeo
Introduction as small arteries arising from branches of the

splenic artery towards the posterior wall of the
Gastric cancer is the fourth most common malig- fundus. If one of these vessels predominates, it is
nancy and the second most common cause of death called the posterior gastric artery.
among all malignancies worldwide [1]. More than The largest blood supply comes from the left
half of new gastric cancer cases come from Eastern gastric artery arising from the celiac axis. The left
Asia (China and Japan), while Korea and Japan gastric artery runs along the lesser curve of the
have the highest incidence rate in the world [2]. stomach and joins with the right gastric artery.
Risk factors for gastric cancer include tobacco The right gastric artery is a branch of the com-
smoking [3], alcohol consumption [4] and a high mon hepatic artery and supplies the region of the
intake of salt and preserved foods [5]. Helicobacter pylorus and lesser curve.
pylori infection is an important risk factor for gas- The blood supply along the greater curve com-
tric cancer having been classified as a class I car- prises of the right gastroepiploic artery arising
cinogen [6], although only 1–3% of patients with H. from the gastroduodenal artery, and the left gastro-
pylori infection go on to develop gastric cancer [7]. epiploic artery arising from the splenic artery.
The mainstay of curative treatment for
gastric cancer is complete resection with
lymphadenectomy. ype of Surgery and Lymph Node
T
Dissection
Anatomy of the Stomach Surgical resection with lymphadenectomy is the

gold standard of treatment for gastric cancer.
The stomach has a rich anastomotic blood sup- Early cancers that meet the following criteria
ply. The blood supply to the uppermost portion of may be suitable for endoscopic resection; T1a
the stomach and the lower esophagus is from a lesion, differentiated-type adenocarcinoma with-
branch of the left inferior phrenic artery. The out ulceration, diameter < 2 cm [8].
upper stomach is also supplied by the short gas- The standard surgery for either clinically node-
tric vessels in the gastrosplenic ligament, as well positive (cN+) or > T2 tumors is either a total or
distal gastrectomy. Distal gastrectomy may be per-
D. Yeo (*) formed when a satisfactory proximal resection mar-
Upper Gastrointestinal and Bariatric Surgery, gin can be obtained, otherwise total gastrectomy is
Department of General Surgery, Tan Tock Seng
performed. Tumors located along the greater curve
e-mail: danson_xw_yeo@ttsh.com.sg with potential lymph node metastasis to station 4sb
https://doi.org/10.1007/978-981-19-3755-2_39
258 D. Yeo
may require a total gastrectomy with splenectomy. • Advanced energy device—author preference
For T1 tumors, a resection margin of 2 cm is recom- is the Harmonic 1000I.
mended, for T2 tumors with expansive growth pat- • Atraumatic graspers.
terns, a proximal margin of at least 3 cm is • Clip applicator.
recommended, while a proximal margin of at least • Suction/irrigation device.
5 cm is recommended for tumors with an infiltrative • Laparoscopic stapler.
growth pattern. If the above cannot be satisfied, fro-
zen section examination of the proximal margin
may be performed to ensure an R0 resection. perating Room Setup and Patient
O
D2 lymphadenectomy is indicated for cN+ Position
or > cT2 tumors while D1 or D1+ lymphadenec-
tomy is sufficient for cT1N0 tumors. D2 lymph- The patient is placed in the supine position with both
adenectomy should be performed whenever the arms out and a footboard. The laparoscopic stack is
possibility of nodal involvement cannot be placed on the patient’s left, the machines for the
excluded or the depth of tumor invasion is energy devices are placed at the patient’s feet, and
uncertain [8]. The Japanese Gastric Cancer the suction machine is placed on the patient’s right.
Association defined the lymph nodes of the The main surgeon stands on the patient’s right
stomach and assigned station numbers [9]. along with the camera assistant, while the first
Lymph node stations 1–12 and 14v are consid- assistant stands on the patient’s left.
ered regional gastric lymph nodes, while metas- After the sub umbilical port is placed, the
tasis to any other nodes is considered metastatic. abdominal cavity is inspected for evidence of
The regional lymph node stations should be peritoneal metastasis. Pneumoperitoneum is
excised according to the type of gastric resec- maintained at 12 mmHg. Rest of the ports are
tion and the extent of lymphadenectomy as placed as shown in Fig. 1. Retract the liver to
detailed in Table 1. expose the hiatus; author’s preference is to use
Contraindications
Gastrectomy as a reduction surgery for advanced

gastric cancer with incurable factors such as unre-
sectable liver metastasis and peritoneal metastasis
is not recommended [8, 10]. Staging laparoscopy
may be performed for patients at high risk of peri-
toneal dissemination, especially if neoadjuvant
chemotherapy is being considered.
Surgical Technique
Instruments
• 3 × 12 mm ports, 2 × 5 mm ports
• Nathanson retractor (not required if alterna-
tive methods of liver retraction are used).
• 10 mm 30° laparoscope Fig. 1 Trocar placement
Table 1 Extent of lymphadenectomy according to the type of gastric resection

Gastrectomy D1 D1+ D2
Subtotal gastrectomy 1, 3, 4sb, 4d, 5, 6, 7 (D1) + 8a, 9 (D1) + 8a, 9, 11p, 12a
Total gastrectomy 1, 2, 3, 4, 5, 6,7 (D1) + 8a, 9, 11p (D1) + 8a, 9, 11p, 11d, 12a
Gastric Carcinoma: Subtotal and Total Gastrectomy 259
the Nathanson liver retractor, others may use tape • Incise the gastrocolic ligament at a transpar-
or sutures to sling the liver or a fan retractor. ent part of the omental bursa at least 3 cm
away from the gastroepiploic arcade (Fig. 3).
• Continue the dissection towards the splenic
flexure until the root of the left gastroepiploic
perative Steps: Distal Gastrectomy
O artery/vein is reached (Fig. 4).
(Fig. 2) –– Be aware of the transverse colon and trans-
verse mesocolon at all times.
issection of the Greater Omentum/
D
Left Gastrocolic Ligament
(Station 4d) igation of Left Gastroepiploic
L
Vessels (Station 4sb)
• The surgeon’s left hand and the assistant lifts
the greater omentum/greater curve of the • The surgeon’s left hand grasps the left gastro-
stomach. epiploic vessels and lifts superiorly.
Fig. 2 Distal
gastrectomy operative
steps
Fig. 3 Dissection of the

greater omentum/left Gastroepiploic
gastrocolic ligament arcade
260 D. Yeo

greater omentum/left
gastrocolic ligament
Fig. 5 Ligation of the

left gastroepiploic
vessels
Spleen
Left
gastroepiploic
vessels
Fig. 6 Ligation of the

left gastroepiploic
vessels Station 4sb
lymph nodes
Left
gastroepiploic
vessels
• A gauze may be placed behind the stomach to the omental and splenic branches between
aid in retraction and visualization of the vas- clips using the energy device (Fig. 6).
cular pedicle (Fig. 5). • The greater curvature vessels are divided
• The left gastroepiploic artery may give off 2 close to the stomach until the avascular area
branches; the omental and splenic branch. The is reached just before the short gastric
left gastroepiploic vessels are divided distal to vessels.
issection of the Greater Omentum/

D igation of the Right Gastroepiploic
L
Right Gastrocolic Ligament Artery (Station 6)
(Station 4d)
• Surgeon’s left hand holds up the right gastro-
• The surgeon’s left hand holds up the gastroepiploic vessels while the assistant lifts up the
epiploic arcade, while the assistant lifts up the posterior stomach and provides countertrac-
stomach. tion (Fig. 9).
• The dissection is continued along the gas- • The right gastroepiploic vein is clipped while
trocolic ligament towards the right gastro- preserving the anterior superior pancreatico-
epiploic vessels and head of pancreas duodenal vein (Fig. 10), while the right
(Fig. 7). gastroepiploic artery is clipped at the junction
• Adhesions between the gastrocolic ligament of the gastroduodenal artery (Fig. 11).
and the transverse mesocolon are best divided • The omentum is dissected off the duodenum/
with blunt dissection to avoid injury to the pylorus (Fig. 12).
middle colic vessels within the transverse –– Be careful to avoid injury to the pancreas.
mesocolon.
• Take down any adhesions between the poste-
rior stomach and pancreas/transverse mesoco- Dissection of the Hepatoduodenal
lon until the gastroduodenal artery is exposed Ligament
(Fig. 8).
–– Be aware of the middle colic vessels that • Place a gauze below duodenum and the hepa-
may be adherent to the gastrocolic toduodenal ligament.
ligament.

greater omentum/right
gastrocolic ligament
Greater
Omentum
Transverse
mesocolon

greater omentum/right Antrum
Station 6
gastrocolic ligament Lymph nodes
Right
gastroepiploic
vessels
Pancreas
262 D. Yeo
Fig. 9 Right
gastroepiploic vessels
Station 6
Lymph nodes
Right
gastroepiploic
vessels
Pancreas
Fig. 10 Right
gastroepiploic vein
Right
gastroepiploic
vein
Pancreas
Fig. 11 Right
gastroepiploic artery
Right
gastroepiploic
artery
• Incise the hepatoduodenal ligament may be encountered during this dissection.

(Fig. 13). Hemostasis can be achieved with the energy
• Surgeon’s left hand holds up the right gastric device.
vessels while the assistant retracts the pylorus
inferiorly. –– The gauze placed posterior protects the
• Dissect the right gastric vessels off the pylorus pancreas and the common hepatic artery
with an energy device, small feeding vessels from injury.
igation of the Right Gastric Artery

L
and Dissection Along the Hepatic
Artery Proper (Station 5)
Antrum
• Hold up the right gastric vessels superiorly,
exposing its origins from the hepatic artery
proper. The lymph nodes at the root of the
right gastric vessels are dissected (station 5
lymph nodes) (Fig. 14).
Pancreas • The right gastric vessels are divided between
clips at the root (Fig. 15).
Fig. 12 Post ligation of the right gastroepiploic vessels
Transection of the Duodenum
• The duodenum is transected with a stapler

(Fig. 16).
Fig. 13 Dissection of
the hepatoduodenal
ligament
Right gastric
artery
Fig. 14 Exposing the

right gastric artery at the Station 5
Lymph
root Nodes
Hepatic Artery Right

Proper gastric
artery
Fig. 15 Ligation of the right gastric vessels Fig. 16 Transection of the duodenum
264 D. Yeo
–– Ensure that the vascular clips are not caught –– Beware of a replaced left hepatic artery
in the stapler jaws prior to firing the arising from the left gastric artery that
stapler. may be traversing the lesser omentum.
• After transection, the stomach is flipped away
to the left to expose the celiac axis (Fig. 17).
issection Along the Common
D
Hepatic Artery and Splenic Artery
Opening of the Hepatogastric (Station 8a, 12a and 11)
Ligament/Lesser Omentum
• The assistant holds up the left gastric vessels
• The lesser omentum is opened up until the superiorly while gently retracting the pancreas
right crus (Fig. 18). inferiorly. Surgeon’s left hand holds up the
fatty tissue over the superior border of the pan-
creas (Station 8a lymph node) and dissects it
off the common hepatic artery. The dissection
may be continued posteriorly along the hepatic
artery to expose the portal vein, thereby taking
Station 12a lymph nodes as well.
• The dissection is continued along the upper
border of the pancreas from the common
hepatic artery (Fig. 19), across the celiac axis
onto the splenic artery to excise Station 11p
lymph nodes along the splenic artery (Fig. 20).
Fig. 17 Expose the celiac axis
igation of the Left Gastric Artery

L
(Station 7, 9)
• The assistant lifts the left gastric vessels and

pulls the pancreas downwards to expose the
celiac axis.
• Dissect out the coronary vein (Fig. 21) and the
left gastric artery (Fig. 22), dividing the ves-
sels between clips (Fig. 23) (The coronary
Fig. 18 Opening of the hepatogastric ligament/lesser vein usually lies anterior to the left gastric
omentum artery).
Fig. 19 Dissection
along the common Station 8a
Lymph nodes
hepatic artery and
splenic artery Hepatic Artery
Proper
Common
hepatic artery
Station 11p Lymph
Nodes Station 11p
Lymph nodes
Splenic
vessels
Pancreas
Fig. 21 Coronary vein
Coronary Vein
Pancreas
Fig. 22 Left gastric

artery
Left gastric
artery
Pancreas
266 D. Yeo
issection of the Proximal Lesser

D • The anterior vagus nerve is transected during
Curve (Station 1) this step.
–– Avoid injury to the distal esophagus during
• The lesser omentum is divided until the esoph- dissection.
agus is reached (Fig. 24).
• The surgeon’s left hand and the assistant holds
up Station 1 lymph nodes to provide traction. Transection of the Proximal Stomach
• Station 1 lymph nodes are excised off the right
crus, the cardio-esophageal junction, and there- • Transection of the proximal stomach is per-
after the lesser curve of the stomach (Fig. 25). formed with a stapler (Fig. 26).
–– Ensure that any nasogastric tube in the
stomach is removed prior to stapling.
–– In cases where there is a concern of cancer
invasion of the proximal staple line, remove
the specimen first for inspection with con-
sideration of frozen section examination of
the proximal staple line.
Figure 27 shows the vessels of the celiac axis

stripped of lymph nodes, and proximal transec-
tion of the stomach completed.
Fig. 23 Ligation of left gastric vessels
the proximal lesser
curve
Esophagus
Station 1
Lymph nodes
Lesser curve
of stomach
Station 1 Lymph nodes
Station 1
Lymph nodes
Right crus
Anastomosis
–– Possible anastomosis includes a Billroth II

anastomosis, Roux-En-Y anastomosis
(Figs. 28 and 29), or Delta anastomosis.
–– Type of anastomosis performed depends on
the surgeon’s experience and patient
factors.
Fig. 26 Transection of the proximal stomach
Fig. 27 Post dissection

of lymph nodes around
the celiac axis
Common Splenic artery

hepatic
artery
Fig. 28 Stapled Roux-En-Y gastrojejunal anastamosis Fig. 29 Stapled Jejunal-jejunal anastamosis

268 D. Yeo
Operative Steps: Total Gastrectomy • Lymph node station 2 dissected off the angle
of His to expose the cardioesophageal junc-
Additional Steps tion on the left (Fig. 31).
• Station 1 lymph nodes are dissected off the
• After ligation of the left gastroepiploic vessels esophagus until the level of the cardioesopha-
(Step 2 of distal gastrectomy), the dissection geal junction (Fig. 32).
is continued cephalad dividing the short gas- • A short distance of the thoracic esophagus
tric vessels until the left crus is reached. may be dissected through the hiatus in order to
• Lymph node station 4sa is taken along with reduce tension in the subsequent anastomosis
the short gastric vessels (Fig. 30). (Fig. 33).
Anastomosis
• Perform a Roux-en-Y esophageal-jejunal

anastomosis.
• Anastomosis can be a side-to-side linear
stapled anastomosis (Fig. 34), an end-to-
side circular stapled anastomosis with an
orvil (Fig. 35), or a handsewn anastomosis.
Fig. 30 Short gastric vessels
Station 2 lymph nodes
Station 2
Lymph nodes
Angle of His
Fig. 32 Dissection of station 1 lymph nodes Fig. 33 Transection of the esophagus

B12 deficiency. Patients with vitamin B12 defi-

ciency may require regular intramuscular vitamin
B12 injections.
References
1. Sitarz R, Skierucha M, Mielko J, Offerhaus GJA,
Maciejewski R, Polkowski WP. Gastric cancer: epi-
demiology, prevention, classification, and treatment.
Cancer Manag Res. 2018;10:239–48.
2. Inoue M, Tsugane S. Epidemiology of gastric cancer
Fig. 34 Linear Stapled side-side anastamosis in Japan. Postgrad Med J. 2005;81(957):419–24.
3. Humans IWGotEoCRt and IARC Working Group.
Tobacco smoke and involuntary smoking. IARC
Monogr Eval Carcinog Risks Hum. 2004;83:1–1438.
4. Glade MJ. Food, nutrition, and the prevention of
cancer: a global perspective. American Institute for
Cancer Research/World Cancer Research Fund,
American Institute for Cancer Research, 1997.
Nutrition. 1999;15(6):523–6.
5. WHO, Joint, and FAO Expert Consultation. Diet,
nutrition and the prevention of chronic diseases.
World Health Organ Tech Rep Ser 2003;916(i-viii),
1–149, backcover.
6. International Agency for Research on Cancer.
Schistosomes, liver flukes and Helicobacter
pylori. IARC Working Group on the Evaluation of
Carcinogenic Risks to Humans. Lyon, 7–14 June
Fig. 35 End-side Circular anastomosis 1994. IARC Monogr Eval Carcinog Risks Hum.
1994;61:1–241.
7. Suerbaum S, Michetti P. Helicobacter pylori infec-
Complications tion. N Engl J Med. 2002;347(15):1175–86.
8. Japanese Gastric Cancer Association. Japanese gas-
tric cancer treatment guidelines 2018 (5th edition).
Patients who are septic post-gastrectomy should Gastric Cancer. 2020.
undergo a Computed Tomographic scan of the 9. Japanese Gastric Cancer A. Japanese classification
abdomen and pelvis with intravenous and oral of gastric carcinoma: 3rd English edition. Gastric
Cancer. 2011;14(2):101–12.
contrast. Potential sources of sepsis include 10. Fujitani K, Yang HK, Mizusawa J, et al. Gastrectomy
pneumonia, intra-abdominal collections, leak plus chemotherapy versus chemotherapy alone for
from the anastomosis, or duodenal stump. advanced gastric cancer with a single non-curable
Long-term complications after total gastrec- factor (REGATTA): a phase 3, randomised controlled
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tomy include dumping syndrome and Vitamin
Part X
Bariatric Procedures
Laparoscopic Gastric Banding
for Morbid Obesity
Davide Lomanto, Emre Gundogdu,

and Mehmet Mahir Ozmen
Obesity is a rapidly rising problem worldwide in There is no single effective treatment that fits
both developed and developing countries. It is all obese patients. Today, there are treatment
not only reducing the quality of life but also options where behavioral therapies, medical
shortens the duration of life with the comorbidi- treatments, endoscopic interventions, and surgi-
ties it brings [1]. Studies show that a two-point cal treatment options are applied alone or in com-
rise in the Body Mass Index (BMI) reduces one’s bination. There is inconsistency in success rates
life expectancy by almost 10 years, and it also and a high rate of regaining weight after treat-
significantly affects the quality of life in mor- ments where nonsurgical weight-loss methods
bidly obese patients [2]. Obesity is a serious are applied alone or in combination [3]. Bariatric
medical problem as it links directly to many com- surgery (BS) often reduces premature mortality
mon comorbidities such as: relative to morbidly obese individuals who have
not undergone weight-loss intervention [4].
• Type II diabetes mellitus. Therefore, surgical options are increasingly con-
• Hypertension. sidered in the treatment of morbid obesity.
• Coronary heart disease. Dietary modification, physiotherapy, drugs, and
• Hyperlipidemia. obesity surgery (if required) is the key approach.
• Asthma. Surgery for weight loss has been devised and
• Sleep apnea. practiced over the last 40 to 50 years. Bariatric
• Reflux esophagitis. surgical procedures cause weight loss by restrict-
• Gallstones. ing the amount of food the stomach can hold,
• Osteoarthritis and spine problems. causing malabsorption of nutrients, or by a com-
• Certain cancers, e.g., breast cancer. bination of both gastric restriction and malab-
sorption. Bariatric procedures also often cause
hormonal changes. In this context the type of sur-
D. Lomanto (*) gery falls into two broad categories:
Department of Surgery, YLL School of Medicine,
National University Singapore, Singapore, Singapore
e-mail: surdl@nus.edu.sg • Restrictive—reduce the size of the gastrointes-
tinal tract, e.g., laparoscopic gastric banding,
E. Gundogdu
Department of Surgery, Liv Hospital, Ankara, Turkey sleeve gastrectomy, vertical gastroplasty.
• Malabsorptive—alter metabolism and reduce
M. M. Ozmen
Department of Surgery, Medical School, Istinye absorption, e.g., gastric bypass, biliopancre-
University, Istanbul, Turkey atic diversion, etc.

https://doi.org/10.1007/978-981-19-3755-2_40
274 D. Lomanto et al.
Bariatric or obesity surgery is recommended for patients with poorly controlled hyperglycemia
the severely obese, in cases where weight reduction with a BMI as low as 27.5 kg/m2 [7, 8].
through medical therapy has been unsuccessful or
where patients suffer from serious complications of
obesity. According to the 1991 National Institutes aparoscopic Gastric Banding
L
of Health (NIH) consensus conference on gastroin- (LAGB)
testinal surgery for severe obesity [5], those who are
suitable for obesity surgery are: Gastric banding is a pure restrictive and reversible
procedure and it is based on the principle of forming
• Patients with a Body Mass Index (BMI)* of a small volume pouch near the stomach by wrap-
more than 40 kg/m2. ping the fundus with various synthetic grafts and
• Patients with a BMI* of more than 35 kg/m2 limiting the passage to the distal part of the stom-
and obesity-related comorbidities. ach. Food intake of patient is reduced by its restric-
tive and satiety effects. With LAGB, patients,
While in the Asian population several studies experience early and prolonged satiety as well as
have shown higher abdominal fat (5–10%) com- reduced appetite. For this purpose, Wilkinson per-
pared to others, so the Indication for Surgical formed the first study on this subject in 1976 using
treatment is 2.5–point BMI less: the Marlex graft wrapped around the stomach [9].
Later, Hallberg and Forsell defined the device,
• Patients with a Body Mass Index (BMI)* of which is now called the Swedish Adjustable Gastric
more than 37.5 kg/m2. Band (SAGB), in 1976 [10]. Also, during this
• Patients with a BMI* of more than 32.5 kg/m2 period, an inflatable silicone-based gastric band,
with obesity-related comorbidities. known today as the American Lap-Band, was
defined by Kuzmak [11]. The first laparoscopic use
* BMI = weight (kg)/height (m) × height (m) of AGB was reported by Dr. Belachew in 1993 [12].
Surgery has become increasingly popular as It is minimally invasive, and the diameter of
they are usually performed via a laparoscopic the band is adjustable through an access port
approach. Several procedures like sleeve gastrec- which is implanted under the skin. Adjustments
tomy, gastric banding, and gastric bypass have of the band are usually carried out at an outpa-
been proven to be very effective not only in tient clinic during follow-up visits and are critical
weight reduction but also in treating all comor- for successful outcomes.
bidities [6]. On average, patients can lose about On the technical point of view after the initial
50–60% of their excess weight. More impor- experience with Belachew’s original technique for
tantly, surgery can result in improvement or com- band placement which is so-called perigastric tech-
plete resolution of the various obesity nique, higher rate of complications like slippage
complications like Diabetes mellitus type II, and pouch dilatation were reported. Subsequently
Hypertension, Obstructive Sleep Apnea, etc. with the modified “pars flaccida technique” several
New guidelines on metabolic surgery in type II studies and RCTS showed a significant reduction of
diabetes treatment algorithm have been published these complications [13, 14].
by international diabetes organizations due to the
increasing data supporting the use of metabolic
surgery for diabetes treatment [7]. Accordingly, Indications
they concluded that bariatric surgery should be
recommended for patients with a BMI 40 kg/ m2 The indications to undergo bariatric surgery are
and those with inadequately controlled hypergly- based on body mass index (BMI) as well as the
cemia and BMI 35 kg/m2 regardless of glycemic presence of comorbidity.
control. In addition, surgery should be considered
for patients with a BMI of 30–34.9 kg/m2 and • BMI ≥ 40 kg/m2, or body weight ≥ 100lbs
poorly controlled hyperglycemia, and for Asian above ideal body weight.
Laparoscopic Gastric Banding for Morbid Obesity 275
• BMI ≥35–<40 kg/m2 and ≥ 1 high-risk gery, are equally important. It is also important to
comorbid condition, or body weight ≥ 80lbs examine patients before the operation in terms of
above ideal body weight + 1 comorbidity. excluding other diseases that may cause weight
• Failure to respond to, low likelihood of gain and to perform laboratory tests. Preoperative
responding to, or refusal to undergo medically upper gastrointestinal system endoscopy is useful
sound weight-loss program. for the exclusion of gastric pathologies. At the
• Well informed and motivated and accepts same time, the presence of preoperative choleli-
operative risk. thiasis should be evaluated with hepatobiliary
ultrasound.
Contraindications • Patient education.

• Psychological evaluation.
• Absolute. • Thorough history and physical examination.
–– Mentally impaired, unable to weigh the • Referral to appropriate specialty.
risk and benefits of surgery. • Screening laboratory tests (FBC, liver func-
–– Active neoplastic disease. tion, HgbA1c, iron, total iron-binding capac-
–– Cirrhosis with portal hypertension. ity, vit B12, folate, vit D, calcium, thyroid
–– Unstable or incurable preexisting comor- function, serum lipid).
bidities (CAD, DM, asthma, AIDS, etc.), or • Gallbladder ultrasound.
uncontrolled psychiatric condition. • Upper GI evaluation.
–– Pregnancy. • Dietary counseling.
–– Immobility. • Preoperative weight loss, esp. BMI >60 kg/m2.
–– Inability or refusal to comply with postop-
erative regimens.
–– Active substance abuse. T Setup, Patient Position,
O
–– Lack of social support. and Operative Team Position (Fig.1)
–– Unable to tolerate general anesthesia.
• Relative. • Video monitor over at patient’s left and right
–– Age. shoulders.
–– Coagulopathy.
–– Previous abdominal surgery.
Preoperative Preparations
Preoperative planning is very important in order

to achieve a successful result in patients who
have undergone bariatric surgery. A group of
qualified medical professionals, such as psychia-
trists/psychologists, nutritionists, cardiologists,
pulmonologists, endocrinologists, surgeons, and
social workers, are an integral part of patient
optimization. Patients often attend group classes
designed to educate them about lifestyle changes
they should follow after surgery and what to
expect during and after surgery. The technical
details of the surgery and the physical changes
that will occur, as well as the adaptation to the Fig. 1 Common operating room setup for bariatric
nutritional and psychological aspects of the sur- surgery
• Patient supine with arms out, preferably split feels comfortable. Generally, a total of four trocars
leg, secured to operative table, reverse are sufficient for this surgery. According to this;
Trendelenburg (about 25°).
• Surgeon between patient’s legs or on the • Port 1
patient’s right side if not split leg; assistant on –– 12–15 mm port
either side of the patient or on the patient’s left –– Midline 8–10 cm supra umbilical, placed
side if not split leg. optimally to view the operative field/work-
ing space (For initiation of working field,
for the laparoscope/camera, for passage of
Instrumentation gastric band).
• Port 2
• Optical Trocar or Veress needle for access. –– 5 mm port
• 5 mm ports (3 or 4) –– Just below the xiphoid for Nathanson liver
• 15– 18 mm port (1) retractor, or
• 30–45° scope, 5 or 10 mm (1) –– Right Subcostal if a Snake Liver Retractor
• Nathanson liver retractor or Snake Retractor (1). is utilized.
• Atraumatic graspers, 5 mm (2). • Port 3
• Maryland dissector, 5 mm (1). –– 5 mm or 10 mm port
• Curved scissors, 5 mm (1). –– Four finger breath below left costal margin,
• Hook diathermy, 5 mm (1). at the anterior axillary line (For left-hand
• Energy-based scalpel (Thunderbeat, Olympus; assisting instruments).
Harmonic™ Ethicon, Ligasure™ Medtronic, • Port 4
etc.), 5 mm (1). –– 5 mm or 10 mm port
• Goldfinger (Obtech, Ethicon) (1). –– Below the right costal margin, at the anterior
• Band placer (1). axillary line (For right-hand instruments).
• Needle holder (2).
• Permanent sutures.
• Gastric band with access port (1). urgical Technique (Pars Flaccida
S
• Suction/irrigation device (1). Technique: (Figs. 3, 4, and 5)
• Dissection at the Angle of His.

Trocar/Port Placement (Fig. 2) –– Retract the liver up and to the right with a
Nathanson retractor, exposing the dia-
The places of incision and the number of trocars to phragm at the esophageal hiatus.
be used are determined in a way that the surgeon –– Using graspers draw down the fundus.
Trocar 1 12mm C
Trocar 2 5mm N 4 3
Trocar 3 (5-10 mm)

C
Trocar 4 (5-10 mm)
Fig. 2 Position of the trocars (left: illustration of the trocar positions, right: anterior view)
–– Dissect the gastrophrenic peritoneal attach-

ment to expose the left crus, using hook
diathermy or energy-based scalpel
(Harmonic™, Ligasure™).
• Dissection at the Lesser Curve.
–– Draw the mid-lesser curve to the patient’s
left, with graspers.
–– Divide the pars flaccida of the lesser
omentum.
–– Retract the posterior wall of the lesser sac
to expose the anterior margin of the right
crus.
Fig. 3 First step of the pars flaccida approach: opening of
–– Make a small opening in the peritoneum
the lesser omentum about 5 mm in front of the anterior margin
of the right crus.
–– Dissect the retroesophagogastric opening
using a blunt instrument or articulating dis-
sector “Goldfinger” (Obtech, Ethicon) until
it exits at the left crus.
• Band Placement and Calibration of Gastric
Pouch (Figs. 6, 7, 8, and 9).
–– Band placer passed gently through the ret-
roesophagogastric tunnel in a
counterclockwise advancement until it

exits at the left crus.
–– Band tubing is inserted into the slot of the
placer.
–– Band placer withdrawn along its path to the
Fig. 4 Second step of the pars flaccida approach: dissec- lesser curve and retrieve the tubing.
tion of the right crus and retrogastric tunnel using avascu-
lar plane dissection
Fig. 5 The retrogastric tunnel is completed reaching the Fig. 6 The goldfinger is utilized to create the retrogastric
left crus using a dedicated instrument called “goldfinger” tunnel
–– Draw the tubing until the band is in place,

and partially close the buckle.
–– Inflate the calibration balloon with 25 ml of
air, withdraw the calibration tube until it
touches the esophagogastric junction.
–– Position the band over the equator of the
balloon.
–– Deflate the calibration balloon, and bring
band to complete closure.
–– Anterior fixation of the fundus and anterior
gastric wall over the band, with three to
four ventro-ventral sutures.
–– Withdraw the calibration balloon.
Fig. 7 The goldfinger is utilized to pass the gastric band-
ing behind the stomach • Placement of Gastric Band Calibration Port.
–– Bring out band tubing through a port site,
with a large loop remaining within to pre-
vent the tube from ripping off the c alibration
port due to extensive movement of patient.
–– Connect band tubing to access port, and
secure to anterior rectus sheath with per-
manent sutures.
Surgical Technique Descriptive
The patient is positioned in the anti-

Trendelenburg position (20–30°) with a slight
inclination to the right and legs apart. The endo-
Fig. 8 The gastric band is then covered by a gastro- laparoscopic monitor is placed on the head of the
gastric flap using 3–4 nonabsorbable seromuscular patient. The operation is started with the surgeon
stitches. The flap must cover completely the anterior part between the legs of the patient and the assistant
of the band
surgeon on the side of the patient.
Pneumoperitoneum can be created either using a
Veress needle Technique (at umbilicus or Palmer
Point), open Hasson technique, or using an
Optical Trocar for an easy access under vision.
The 12–15 mm optical trocar is inserted on the
midaxillary line four fingers below the left costal
margin. Then, one 5 mm and two other 5–10 mm
cannulas were inserted as in Fig. 2. Two are the
working port and the right subcostal utilized for
liver retraction if not a subxiphoid Nathanson
Retractor is used. The left lobe of the liver is
elevated to expose the cardia of the stomach and
the diaphragmatic crus. The dissection starts
Fig. 9 Then the port reservoir is sutured at the abdominal from the greater curvature and continues towards
fascia the diaphragm, and, at this stage, the left parae-
sophageal ligament dissection is completed, and • Adjustment of gastric band usually starts
the left crus is exposed. Then, the pars flacida is 4–6 weeks after operation and every 4–6 weeks
opened and the peritoneal sheet close to the edge thereafter based on the patient’s rate of weight
of the right crus is opened to enter the retrogas- loss and food-fluid tolerance.
tric area. A retrogastric tunnel is created using a • Goal of gastric band adjustment.
“Goldfinger instrument” or an atraumatic grasper –– Loss of excess weight within 18 months to
till reaching the left crus and the phrenogastric 3 years.
ligament. During this step, we avoid the use of –– Weight loss of 0.5–1.0 kg per week.
calibrated tube or balloon to avoid injury of the –– Sensation of prolonged satiety.
posterior GE wall. The band is inserted and –– No negative symptoms.
passed through the retrogastric tunnel and closed • Adjustment of Gastric Band (two different
over the bucket, then secured by anterior gastro- type).
gastric sutures using three or four nonabsorbable –– SAGB (high volume, low pressure).
seromuscular stitches. This is to cover the ante- 3–4 cc of fluid added at first adjustment
rior part of the band completely. If any injury or 1–1.5 cc of fluid on subsequent
laceration of the posterior gastric wall is sus- adjustment
pected, a methylene blue dye test is carried out. Final total volume of 6–8.5 cc.
The connecting tube is passed through the subxi- –– LAP-BAND (low volume, high pressure).
phoid port and connected to the port placed and 0.5–1.0 cc of fluid added at first
anchored over the left rectus abdominis. The adjustment
gastric band can be calibrated if needed after 0.3–0.5 cc of fluid on subsequent
3–4 weeks, with water/saline injection. adjustment
Additional calibrations were later considered Final total volume of 3–5 cc.
based on clinical evaluation of symptoms and • Adjustment Guidelines.
weight loss during follow-up. –– Adjustment not necessary.
Adequate rate of weight loss.
No negative symptoms.
Postoperative Care Eating reasonable range of food.
–– Consider adding fluid.
In order to keep the gastric band in the optimal Inadequate weight loss.
position, it is very important to follow the patients Rapid loss of satiety after meals.
with an appropriate diet program. The gastric Hunger between meals.
passage may be narrowed due to postoperative Increased volume of meals.
edema of the gastric mucosa. Patients are started –– Consider removing fluid.
on the postoperative diet with liquids and con- Vomiting, heartburn, reflux into the
tinue with pureed, soft, and solid foods for a mouth.
period of 3–4 weeks. These dietary guidelines Choking, coughing spells, wheezing;
should be given to patients in writing with the especially at night.
support of a dietician in the clinic. Patients may Difficulty with a broad range of food.
not be able to lose weight in this early period Maladaptive eating behavior.
because the feeling of satiety caused by the band
has not yet formed. When they start eating solids,
they will often need reassurance that they will ide-Effect and Complications after
S
start losing weight [15]. LAGB (Table 1)
• Upper GI gastrografin study on the first post- Band patients require long-term follow-up and
operative day; if normal findings, patient are likely to require adjustments to the band on a
allowed to take fluids then structured diet. regular basis. Even in the experienced hands
Table 1 Complications after LAGB with secondary acute pouch dilatation. Late
Minor complications complications include pouch dilatation, band
• Acute stomal obstruction herniation, spontaneous variation in volume,
• Minimal bleeding erosion of the gastric wall, and migration of the
• Port infection band.
• Delayed gastric emptying
Major complications
• Gastric/esophageal perforation
• Hemorrhage Slippage
• Band erosion
• Band slippage/prolapse A gastric band can migrate distally along the
• Port/tubing malfunction stomach or the stomach proximally above the
• Port/tube leakage band. Most gastric band slippages are anterior
• Esophageal dilatation and present chronically [23]. A posterior band
slippage is rare but can occur if the gastric band
has been placed within the lesser sac of the stom-
10–20% of patients who have weight-loss opera- ach. Misplacement of the band is usually caused
tions require follow-up operations to correct by the surgeon’s lack of experience and rarely
complications [16]. The majority of revision sur- occurs when the surgeon is experienced. The
geries are minor revisions due to minor compli- band may be placed in the perigastric fat not a
cations such as port revision and repositioning. constant finding, and the diagnosis may be
Abdominal hernias are the most common com- delayed for a few days. The use of barium has
plications requiring follow-up surgery. More than been controversial because it may cause inflam-
one-third of obese patients who have gastric sur- mation and fibrosis in these critically ill patients
gery develop gallstones [17]. During rapid or or in the lower part of the stomach, the latter
substantial weight loss a person’s risk of develop- causing severe gastric outlet obstruction.
ing gallstones is increased. Gallstones can be pre-
vented with supplemental bile salts taken for the
first 6 months after surgery [18]. Perforation
Nearly 30% of patients who have weight-loss
surgery develop nutritional deficiencies such as As with any laparoscopic surgery, hollow organ
anemia, osteoporosis, and metabolic bone dis- perforations can be seen after LAGB, but specific
ease. These deficiencies can be avoided if vita- to this procedure, perforations usually develop in
min and mineral intake are maintained. Women the cardia of the stomach [24]. This early gastric
of childbearing age should avoid pregnancy until perforation is usually due to surgical trauma to
their weight becomes stable because rapid weight the stomach wall. The patient presents with fever,
loss and nutritional deficiencies can harm a pain, and leukocytosis. Water-soluble contrast
developing fetus [19, 20]. imaging may reveal the leakage from the stom-
Regarding the complications, LAGB is the ach. However, leakage is not a constant finding,
obesity surgery with lowest rate of complications and the diagnosis may be delayed for a few days.
and mortality (0.2–0.4%) [21, 22]. The most The use of barium has been controversial because
common complications that require an interven- it may cause inflammation and fibrosis in these
tion are band slippage, erosion and perforation, critically ill patients and is probably better
and port/tube dysfunction or infection. avoided if there is definite evidence of leakage.
Early complications are seen in the immedi- Gastrografin is an alternative option. CT is also
ate postoperative period and include misplace- diagnostic, showing the leakage and the possible
ment of the band, perforation, and early slippage associated subphrenic abscess.
Pouch Dilation band diameter. The incidence of port-related

revisions is around 6% and the majority of these
Early pouch dilatation has been described in low- are for the management of leaks [27].
positioned bands. Pouch dilatation is also a com-
mon late complication. After surgery, the pouch
gradually increases in volume but retains a Infection
grossly concentric shape. It may also be second-
ary to overinflation of the band or to eccentric As around any foreign body, soft-tissue infection
band herniation that results from focal band around the access port is possible. In addition,
weakness. A contrast X-ray swallow test will even the sterile puncture and adjustment of the
identify the gastric pouch enlargement, diagnos- stoma size may introduce infection, which then
tic of a pouch dilatation. Management of a pouch extends along the connector tube and along the
dilatation should consist of initial band deflation band, with possible abscess formation. Infection
with the pars flaccida approach, where with mini- increases the risk of perforation and fistulization
mal dissection and higher position of the band, and may necessitate surgical debridement and
there is less risk for dilation. Slippage of the band removal of the band.
can cause eccentric pouch dilation [25]. Since its introduction in 1993, laparoscopic
adjustable gastric banding has been the subject of
many studies and evaluations. The continuous prog-
Erosion ress in surgical technique and increasing experience
of surgeons have decreased the rate of many com-
The clinical presentation of chronic gastric ero- plications. LAGB procedure has been a very popu-
sion varies between asymptomatic conditions lar procedure for a while due to the relatively low
and acute abdominal emergency. Mechanical learning curve, being technically easy, the duration
damage to the wall may be secondary to intraop- of hospitalization is short, it can be applied as out-
erative trauma to the muscular layers, inflamma- patient operations in some places, the early compli-
tory reaction to foreign bodies, infection, and use cation rates are low, and the desired level of weight
of nonsteroidal anti-inflammatory medication. it loss can be achieved due to the adjustment of the
is eventually a consequence of local gastric isch- band [28, 29]. The popularity of Gastric Banding
emia secondary to a tight band and the incidence was at the peak around 2008–2010 (about 40% of
of erosion following gastric band surgery remains bariatric procedures worldwide) and then due to the
currently at around 1% [26]. The passage of the high number of long-term and serious complica-
contrast out of the lumen around the band is a tions such as weight gain, obstructive symptoms,
certain indication of band erosion. Gastric ero- dysphagia, band slippage, esophageal dilatation,
sion is highly likely if an open band is seen. esophagitis, and gastric erosion and also the advent
Findings may be associated with a change in of other restrictive procedures like sleeve gastrec-
band position. tomy the frequency of LAGB procedures went
down dramatically worldwide [30, 31]. Many
patients and surgeons today prefer procedures like
Leakage of the Banding System Laparoscopic Sleeve Gastrectomy or Roux-en-Y
gastric bypass as an alternative to gastric banding.
Leakage is typically a late complication. It may However, even though results have shown the effi-
occur at the level of the band or the connector cacy of the banding in weight loss, controlling
tube or at the access port. It is first suspected comorbidities such as diabetes mellitus II, hyper-
when filling and insufficient deflating volume of tension, and OSA when the long-term results
the banding system combined with loss of eating showed failure in weight loss, weight regain, long-
restriction are observed Leakage of contrast term complications, banding becomes less and less
material is usually detected while adjusting the utilized today [25, 28, 32, 33].
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P, Anderson ML, OʼBrien PE. Erosions after laparo- States in 2016. Surg Obes Relat Dis. 2018;14(3):259–
scopic adjustable gastric banding: diagnosis and man- 63. https://doi.org/10.1016/j.soard.2017.12.013. Epub
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27. Tog CH, Halliday J, Khor Y, Yong T, Wilkinson Dapri G. Long-term outcomes of laparoscopic adjust-
S. Evolving pattern of laparoscopic gastric band access able gastric banding. Arch Surg. 2011;146(7):802–7.
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28. Chang SH, Stoll CR, Song J, Varela JE, Eagon CJ, JP, Berta JL, Altman JJ, Cugnenc PH. Complications
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29. Chapman AE, Kiroff G, Game P, Foster B, O'Brien P,
Ham J, Maddern GJ. Laparoscopic adjustable gastric
Laparoscopic Sleeve Gastrectomy
Bariatric surgery (BS) has proved its role in treat- cases of super-obesity before procedures like
ing obesity and related comorbidities. The num- Roux-en-Y gastric bypass or the duodenal switch
ber of Laparoscopic Sleeve Gastrectomies can be performed [6]. The objective is to achieve
(LSGs) performed globally has increased mark- an initial weight loss that would help to perform
edly and has become “trendy” among bariatric more extensive mixed restrictive or malabsorp-
surgeons in the last few years [1]. LSG has tive procedures safely and effectively [7–9].
attained its position as the primary procedure of
choice in bariatric surgery for morbid obesity. In
this procedure, 80% of the stomach, mainly the Indications
body and fundus are removed longitudinally,
leaving behind a sleeve of the stomach along the • First stage procedure before a more complex
lesser curve [2, 3]. The procedure can be per- procedure for BMI > 60.
formed by minimally invasive approaches as well • Preferred bariatric procedure for the high-risk
as single incision access or even robotic surgery obese BMI 35–40.
with comparable results [4, 5]. The weight loss is • Revision of previous laparoscopic adjustable
achieved by restricting the food entering the gastric banding (LAGB).
stomach. Another factor in the effectiveness of • Redo LSG.
weight loss in sleeve gastrectomy is the decrease
in blood levels of ghrelin, “the hormone that
stimulates hunger,” and a majority of cells Contraindications
responsible for producing this hormone is found
in the fundus which is removed during this proce- • Extensive previous surgery.
dure. This procedure can be performed as the first • Crohn’s Disease.
stage in more complex bariatric cases including • Elderly patients with extensive comorbidities.
S. Malik (*)
Department of General Surgery, Allama Iqbal Preoperative Preparation
Medical College, Jinnah Hospital, Lahore, Pakistan
S. Wijerathne • Weight and height measurement on a standard
Department of Surgery, National University Health electronic scale.
System, Singapore, Singapore • Nutritional parameters.
General Surgery Services, Alexandra Hospital • Evaluate cardiopulmonary function.
Singapore, Queenstown, Singapore • Obstructive sleep apnea tests.
https://doi.org/10.1007/978-981-19-3755-2_41
286 S. Malik and S. Wijerathne
• 2 weeks on low or very low caloric diet • Another 5 mm port is placed in right epigas-
• Upper GI endoscopy. tric region for liver retraction.
• Testing for Helicobacter pylori. • Another 12/15 mm port is placed in mid epi-
• Psychiatric evaluation. gastrium in the midline.
• Chemoprophylaxis. • Another 5 mm port is placed on the right side
• Thromboprophylaxis. lateral to the 12/15 mm port.
• Left lobe of the liver is retracted using a snake
retractor.
Instruments
For LSG, Laparoscopic tray with full set of Operative Techniques

instruments is required, including endoscopic
gastrointestinal anastomosis (GIA) staplers, and After the pneumoperitoneum is created, a diag-
silk and polyglactin sutures nostic laparoscopy is done to exclude other
pathologies. The liver is retracted cranially, and
• Energy device (Ultrasonic or Advanced bipo- the GE junction is exposed (Fig. 1). A point in the
lar or combined). greater curve is identified and marked at 6 cm
• 3 × 5 mm ports proximal to the pylorus as the distal extent of the
• 1 × 10 mm ports resection (Fig. 1).
• 1 × 15 mm port Division of the greater omentum to enter the
• 1 × Optical-view Trocar lesser sac and division of short gastric vessels is
• 1 × Dissecting forceps achieved by using an energy device along the
• 2 × Bowel graspers gastrocolic and gastrosplenic ligaments from the
• 1 × Babcock forceps greater curvature up to the angle of His (Figs. 2,
• 1 × Bowel Grasper Single Action 3, and 4). Be aware of gastroduodenal and right
• 1 × Curved scissors gastric artery at pylorus and stop dissection about
• 1 × L-hook 5 cm proximal to it to prevent injury to these ves-
• 1 × Suction Irrigation 5 mm/10 mm cannula sels and to preserve perfusion of the pylorus and
• Nathanson/Snake liver retractor. the distal antrum [7]. Make sure to dissect closely
• Clip Applicator with Hemolock. along the greater curvature leaving no fat behind.
• 1 × Needle holder curved Next step is to lift and pull the stomach to the
• 1 × Veress Needle. right of patient to have a better view of gastro-
Patient and Trocar Positions
• Supine with reverse-Trendelenburg position.

• Foot support on board.
• Anti-embolic precautions.
• Prophylactic antibiotics.
• 12 mm Optical port is placed under direct
vision approximately 15 cm below the xiphoid
process and almost 4 cm left to the midline.
• Pneumoperitoneum is created and 30 laparo-
scope is introduced.
• A 5 mm port is placed in left lateral flank at
the same level as the optical port. Fig. 1 Placement of boogie and placing it on suction
Laparoscopic Sleeve Gastrectomy 287
esophageal (GE) junction along with left crus

and spleen to dissect down any adhesions on pos-
terior wall of stomach (Fig. 4). Last of few short
gastric vessels in this area can be divided along
the left crus. The greater curvature must be com-
pletely freed up to the left crus of the
diaphragm.
Next step is to position the bougie (size 36 Fr)
in the stomach before using stapler. Afterward
linear cutting staples are used to vertically tran-
sect the stomach creating a narrow gastric tube
with an estimated capacity of less than 150 ml.
Check location of anvil and cartridge both anteri-
orly and posteriorly to achieve optimized stapling
Fig. 2 Dissection started at 6 cm proximal to pylorus to (Figs. 5 and 6). It is important to compress the
enter lesser sac line of transection of the gastric tissue with the
Fig. 3 Lesser sac entry

Fig. 5 First cutting staples
Fig. 6 View of posterior wall and less curve to check the

Fig. 4 Posterior wall of stomach position of stapler
staple for 15 s prior to firing, to get adequate this point. Next reinforcement sutures can be
hemostasis and stapling of gastric tissues. First, applied to any areas of bleeding and omentopexy
stapler is usually 60 mm black or green cartridge to prevent volvulus; however, these measures are
for the antrum. Gold cartridges can be used debatable and must be practiced as tailored
together with Seamguards to prevent staple line approach for individual cases.
bleeding and leaks. Second, cartridge should be Role of drains in the subhepatic space adja-
green, black, or purple depending on the sur- cent to the gastric tube is controversial and is not
geon’s choice, but smaller cartridges than those recommended. The resected stomach is placed in
mentioned above are not recommended in this a specimen bag or even can be directly extracted
region. Care must be taken to avoid stenosis at through the epigastric 15 mm port site. Fascial
incisura (Fig. 7). It is good practice to rotate the sutures are not routinely used for 5 mm or 10 mm
stomach and stapler anteriorly to have a look at port sites, but 15 mm port site fascia should be
the posterior wall before firing the stapler and closed to prevent future port site hernia.
distal end must be at least 2 cm from GE junction
(Fig. 8). Hold the “new” stomach and ask anes-
thetist to off the suction and remove the bougie, When to Convert
observe for few minutes for any bleed or leak at
• Massive blood loss.
• Dense adhesions.
ajor Post-op Complications

M
and Management
Hemorrhage
Risk of postoperative bleeding is from 1–5% and

the source could be intraluminal or extraluminal.
Intraluminal bleeds can present as melena or
hematemesis due to bleeding from staple line.
Upper GI bleeding protocol should be followed.
Large-bore IV cannula, fluid resuscitation, Input/
Fig. 7 Observe staple line
output monitoring, and blood transfusion if
needed should be practiced. Urgent Upper GI
endoscopy to locate and control the bleeding is
warranted.
Extraluminal bleeding is commonly from
staple line, injury to abdominal viscera, or from
port site. These patients presents with drop of
serial hemoglobin, tachycardia, or occasionally
hypotension. Urgent diagnostic laparoscopy
helps to make the diagnosis and to evacuate
hematoma along with control of source of bleed-
ing. Even if source is not identified, hematoma
evacuation and drain placement serve as a
Fig. 8 last stapler 2 cm from GE junction treatment.
Laparoscopic Sleeve Gastrectomy 289
Staple Line Leak of the stomach. Avoid pushing the bougie too dis-
tally which can result in shorter and larger than
Staple line leak is the most dreadful complication expected gastric tube when bougie is removed.
of LSG which can occur in approximately 2–3% Endoscopic balloon dilatations with multiple ses-
of patients [10]. Based on upper GI contrast stud- sions can be used to treat stenosis with or without
ies and radiological findings, leaks are divided an alternative option of stenting. If recurrent or
into two types: Type I is a controlled leak and unresolved after dilatation then Roux-en-Y
could be easily managed with aspiration, drain- Gastric Bypass (RYGB) is a treatment option.
age, or through a natural fistulous tract forma-
tion; Type II is a disseminated variety and needs
an urgent diagnostic laparoscopy, wash out and Portal Thrombosis
surgical repair of leak if technically feasible.
Enteral nutrition with feeding jejunostomy is pre- This rare complication occurs in almost 0.3–0.5%
ferred as the mode of feeding in these patients. of cases. Several factors like splenic ischemia,
Early and delayed presentations are classified dehydration in early postoperative period, varia-
based on the time of presentation after surgery tion in blood flow after resection of vessels along
(either within 3 days or after 8 days, greater curvature, and thrombophilia can contrib-
respectively). ute to this. Clinical severity is the predictor of the
Treatment of delayed and disseminated vari- outcome of treatment which includes holding off
ety is challenging because of hemodynamic oral feeding and providing IV fluids for
instability of patient and inflammatory reaction rehydration. Anticoagulation should be consid-
leading to sepsis [11]. Treatment in this condition ered even on slightest suspicion. Treatment with
involves vigorous resuscitation with fluids, IV therapeutic dose of low molecular weight heparin
antibiotics, holding off oral feeding, aspiration/ for 5–7 days and bridging therapy with oral anti-
drainage under radiological guidance, followed coagulation with Warfarin to keep INR between
by surgical repair of leak as a definitive proce- 2–3 for 3–6 months is needed. Surgical options
dure [12]. for portal thrombosis are reserved for compli-
cated cases like thrombosis leading to splanchnic
ischemia [15, 16].
Stenosis
This rare complication is observed in less than Postoperative Care

2% of patients and needs urgent attention once
diagnosed. Patients present with vomiting, regur- 1. Admit to ICU or Surgical High Dependency
gitation, or feeling of fullness [13]. It is further unit for close monitoring for signs of obstruc-
subdivided into two subtypes anatomical or func- tive sleep apnea.
tional stenosis which determines the treatment 2. Diet is maintained on general liquids for
options in both groups. Upper GI endoscopy is a 1 week and gradually progressed by the
good initial investigation to diagnose anatomical dietician.
variety but tridimensional CT with 3D recon- 3. Encourage early sitting up on the bed and if
struction is a diagnostic modality with good sen- possible early ambulation.
sitivity for functional groups [14]. 4. Chest physiotherapy.
Intraoperatively to prevent stenosis, the endo- 5. Continue mechanical deep vein thrombosis
luminal bougie should be placed along the lesser prophylaxis during the rest of hospitalization.
curvature going all the way distal to the antrum 6. Gradual exercise is started 1 month after the
and avoid excessive lateral traction and twisting operation with advice from a physiotherapist.
References 10. Márquez MF, Ayza MF, Lozano RB, et al. Gastric leak
after laparoscopic sleeve gastrectomy. Obes Surg.
2010;20:1306–11.
1. Buchwald H, Oien D. Metabolic/bariatric surgery
11. Himpens J, Dapri G, Cadiere GB. Treatment of leaks
worldwide 2011. Obes Surg. 2013;23:427–36.
after sleeve gastrectomy. Bariatric Times. 2009.
2. Young MT, Gebhart A, Phelan MJ, Nguyen NT. Use
http://bariatrictimes.com/treatment-of-leaks-after-
and outcomes of laparoscopic sleeve gastrectomy vs
sleevegastrectomy/. Accessed 29 October 2012.
laparoscopic gastric bypass: analysis of the American
12. Oshiro T, Kasama K, Umezawa A, et al. Successful
College of Surgeons NSQIP. J Am Coll Surg.
management of refractory staple line leakage at
2015;220:880–5.
the esophagogastric junction after a sleeve gas-
3. ASMBS Clinical Issues Committee. Updated position
trectomy using the HANAROSTENT. Obes Surg.
statement on sleeve gastrectomy as a bariatric proce-
2010;20:530–4.
dure. Surg Obes Relat Dis. 2012;8:e21–6.
13. Goitein D, Matter I, Raziel A, Keidar A, Hazzan D,
4. Elli E, Gonzalez-Heredia R, Sarvepalli S, Masrur
Rimon U, et al. Portomesenteric thrombosis follow-
M. Laparoscopic and robotic sleeve gastrec-
ing laparoscopic bariatric surgery: incidence, patterns
tomy: short- and long-term results. Obes Surg.
of clinical presentation, and etiology in a bariatric
2015;25:967–74.
patient population. JAMA Surg. 2013;148:340–6.
5. Maluenda F, Leon J, Csendes A, Burdiles P, Giordano
14. Rebibo L, Hakim S, Dhahri A, Yzet T, Delcenserie
J, Molina M. Single-incision laparoscopic sleeve gas-
R, Regimbeau JM, et al. Gastric stenosis after lapa-
trectomy: initial experience in 20 patients and 2-year
roscopic sleeve gastrectomy: diagnosis and manage-
follow-up. Eur Surg. 2014;46:32–7.
ment. Obes Surg. 2016;26:995–1001.
6. Silecchia G, Boru C, Pecchia A, Rizzello M, Casella
15. Condat B, Pessione F, Helene Denninger M, Hillaire
G, Leonetti F, Basso N. Effectiveness of laparoscopic
S, Valla D. Recent portal or mesenteric venous
sleeve gastrectomy (first stage of biliopancreatic
thrombosis: increased recognition and frequent
diversion with duodenal switch) on comorbidities
recanalization on anticoagulant therapy. Hepatology.
in super-obese high-risk patients. Obes Surg.
2000;32:466–70.
2006;16:1138–44.
16. Hamoui N, Anthone GJ, Kaufman HS, Crookes
7. Santoro S. Technical aspects in sleeve gastrectomy.
PF. Sleeve gastrectomy in the high-risk patient. Obes
Obes Surg. 2007;17(11):1534–5.
Surg. 2006;16(11):1445–9.
8. Himpens J, Dobbeleir J, Peeters G. Long-term results
of laparoscopic sleeve gastrectomy for obesity. Ann
Surg. 2010;252(2):319–24.
9. Frezza EE. Laparoscopic vertical sleeve gastrectomy
for morbid obesity. The future procedure of choice?
Surg Today. 2007;37:275–81.
Laparoscopic Roux EN y Gastric
Bypass (LRYGB)
Rajat Goel, Chih-Kun Huang,

and Cem Emir Guldogan
Introduction standard BS procedure giving the above benefits

for a longer period of time. LRYGB is also asso-
Edward Mason introduced a different approach ciated with lifelong follow-up like other bariatric
to bariatric surgery (BS) in 1966, inspired by the surgeries and requires stringent intake of multivi-
observation that subtotal gastrectomies often tamins, calcium tablets, vitamin d supplements,
cause weight loss (WL) [1]. The first gastric and Iron for long periods of time to prevent
bypass procedure was performed by horizontal nutrition-related side effects a few years down
section of 10% volume of the upper stomach and the line.
anastomosis into the jejunal loop, excluding 90% With LRYGB method, up to 25% total body
of the gastric reservoir. Wittgrove and Clark WL (68.2% excess WL) can be achieved in the
established a standard technique for laparoscopic long term [5, 6]. After LRYGB, WL was attrib-
gastric bypass in 1991 [2]. Similar progressive uted to consuming a smaller volume and bypass-
improvement in the results of Laparoscopic ing the jejunum. However, it is likely that there is
Roux-en-Y Gastric Bypass (LRYGB) is reported a complex interplay of physiological mechanisms
in most large series around the world [3, 4]. including food intake, food preferences, calorie
BS or Metabolic Surgery (MS) has given mor- restriction, and energy expenditure.
bidly obese patients sustainable WL and better or Early complications occur in approximately
complete control of weight-related comorbidities 4% of patients after LRYGB. The most common
like Type 2 Diabetes Mellitus (T2DM), hyperten- complications are bleeding, perforation, or leak-
sion (HT), hyperlipidemia (HL), obstructive age requiring immediate surgical intervention
sleep apnea, joint pain, and others. Laparoscopic [7]. In 15–20% of patients, late complications
Roux-en-Y (LRYGB) is considered the gold such as abdominal pain, obstruction, anastomotic
stricture, and marginal ulcers may occur up to
10 years after surgery [8, 9].
R. Goel
Supreme Superspecialty Hospital, Faridabad, India
Aakash Healthcare Superspeciality Hospital, Patient Selection and Indications
Dwarka, New Delhi, India
C.-K. Huang Medical treatment can be tried in morbid obesity,
Body Science & Metabolic Disorders International
Medical Center, China Medical Hospital,
but failure rates are still very high, patients can be
Taichung, Taiwan evaluated for surgery after medical treatment
C. E. Guldogan (*)
fails. NIH has determined some conditions for
Department of Surgery, Liv Hospital, Ankara, Turkey patients who want to have BS in 1991 [10]. The
https://doi.org/10.1007/978-981-19-3755-2_42
292 R. Goel et al.
Society of American Gastrointestinal Endoscopic style and dietary changes, regular follow-ups,
Surgeons (SAGES) has similar recommendations and need for prolonged supplement usage.
[11].
• Patients who are unlikely to respond to medi- Preoperative Investigation

cal treatment.
• Patients who are motivated and informed Blood Investigation
about surgical risks.
• Patients with a body mass index (BMI) > 40 kg/ Complete blood count, Blood Group, Renal
m2. Function Test, Liver Function test, PT/INR,
• Patients with BMI between 35 and 40 kg/m2, PTTK, Lipid Profile, Thyroid Profile, Blood
with one high-risk comorbid condition. sugar random (Blood sugar Fasting and
Postprandial, HbA1C, C peptide level if
In Asian setup, the following guidelines are Diabetic), Vitamin B12, and Vitamin D3.
followed
1. X-ray Chest.
• BMI >37 kg/m2 irrespective of comorbidity. 2. ECG and 2D ECHO or 2D Stress Echo (If
• BMI >32 kg/m2 in the presence of T2DM or hypertensive).
two or more obesity-related comorbidities. 3. Upper Gastrointestinal Endoscopy (to rule out
H. Pylori Infection).
These guidelines ensure that patients can be 4. Ultrasound Examination of whole abdomen
properly classified for surgery, and patients can (to rule out gall stones) and if present
be prepared for surgery. Cholecystectomy should be planned with bar-
iatric even if asymptomatic.
5. Urine Routine and Microscopy.
Contraindications 6. Ultrasound Doppler Bilateral Lower Limb
Venous System (to rule out DVT).
• Contraindications of General Anesthesia.
• Intractable Coagulopathy.
• Metastatic or Inoperable Malignancy. OT Setup and Port Positioning
• Cirrhosis with Portal Hypertension (Type B
and C Budd Chiari Classification). Patient’s Position
• Inflammatory Bowel Disease.
• Previous Surgery involving small bowel All long instruments, Nathanson’s Liver
resection. Retractor, and 45°long scope should be ready.
• Relative contraindications include large ven- Patient should be in Supine position or split leg
tral hernia, multiple previous abdominal sur- according to surgeon preference with secure
geries, extremes of age (<18 and >65), alcohol/ strapping and padding of bony points and table
drug abuse. should be checked for reverse Trendelenburg
position. We catheterize all patients routinely.
Note: Surgery should be deferred if the patient (Fig. 1).
plans for pregnancy within 12–18 months.
Port Positioning
Preoperative Assessment
Our preferred entry is by 0 telescope mounted on
The most important aspect for long-term success 12 mm 15 cm long Optiview trocar in the left
of LRYGB is proper counseling regarding life- midclavicular line 15–18 cm from Epigastrium.
Laparoscopic Roux EN y Gastric Bypass (LRYGB) 293
Fig. 1 (a) Patient’s position. (b) Port placement
1. Second Trocar is inserted 5 or 12 mm Surgical Technique

15–18 cm from epigastrium in right midcla-
vicular line (Surgeon port). Step 1: Creation of gastric pouch: Patient is
2. Third 12 mm trocar is inserted a palm breadth placed in steep reverse Trendelenburg posi-
from second trocar in right upper abdomen tion. Dissection is done along lesser curvature
(Surgeon port). starting between first and second vessel from
3. Fourth 5 mm port through epigastrium for gastroesophageal junction. A retrogastric tun-
liver retractor. nel is created by blunt dissection and energy
4. Fifth 5 mm port palm breadth from first on left source. A 60 mm linear blue or purple stapler
upper abdomen (Assistant Port) (Fig. 1b). applied transversely from port 3 and followed
by Vertical 60 mm Blue or Purple firings [2–3]
294 R. Goel et al.
from port 2 to create 25–30 ml pouch is cre-

ated over 36 french bougies. Gastrotomy is
created at distal most part of the pouch for
Gastrojejunostomy (Fig. 2).
Step 2: Fashioning of Gastrojejejunostomy:
Patient is made supine. Transverse Mesocolon
mesentery is lifted to identify DJ Flexure
(Ligament of Treitz) and small bowel is
counted 70–100 cm (Depending on BMI kg/
m2) and 45 cm blue or purple stapler is used
and Gastrojejunostomy is fashioned and enter-
otomy closed by vicryl 2/0 after performing
Jejuno-jejunostomy. Now Patient is again
made reverse Trendelenburg. The patency of
Gastrojejunostomy is checked by smooth pas-
sage of Orogastric Tube. Leakage is checked
Fig. 2 Creation of Gastric pouch
by methylene blue dye test (Fig. 3).
Step 3: Side to Side Jejuno-Jejunostomy: 60 mm
white stapler is used to form BilioPancreatic
limb just distal to Gastrojejunostomy. Now
100 cm Alimentary Limb is counted and Side
to side Jejuno-Jejunostomy is fashioned by
60 mm white stapler and enterotomy closed
by vicryl 2/0 (Fig. 4).
Step 4: Closure of Mesenterc defects: Both
Jejeunojejunostomy and Petersen defects are
closed by nonabsorbable 2/0 Ethibond sutures.
Step 5: Drain Insertion and closure of defects:
One Jackson Pratt drain is put close to
Gastrojejunostomy anastomosis and all ports
are closed (12 mm ports are closed in layers
and 5 mm only skin is closed).
Fig. 3 Fashioning of Gastrojejunostomy
Post-op Course
Patient is kept NPO on the day of surgery and put

on pantoprazole infusion (80 mg in 50 ml normal
saline at 5 ml/h). Patient is started on oral sips on
post-op day1 and mobilized with chest physio-
therapy and Incentive spirometry. On postopera-
tive day 2 30–50 ml clear liquid is started and the
patient is discharged with one dose of protein
solution. Gradually Clear liquid fluid is escalated
to 80–100 ml per hour followed by blend diet and
full small meals over a period of 1–2 months.
Note patient should not drink water 30 min before
and 30 min after every meal. Patient should not
use any straw. Most important is complete absti- Fig. 4 Side to side Jejuno-jejunostomy
Laparoscopic Roux EN y Gastric Bypass (LRYGB) 295
nence from Alcohol and Smoking to prevent any standard treatment protocols. Weight regain
complications. Another important point is the treatment will vary from diet counseling,
continuous intake of multivitamins, Calcium, redosurgery (Limb lengthening/fundec-
VitaminD3, and Iron throughout life. Patient is tomy). Internal hernias are rare if both mes-
also advised for complete laboratory checks once enteries are closed but if any doubt exists
a year and monthly meetings with the physician immediate Diagnostic laparoscopy or
and should be encouraged to attend support group Exploratory Laparotomy should be done.
meetings. Nutritional deficiencies have to be dealt
with on case to case basis and may even
require reversal of procedure in extreme
Common Complications cases.
• Bleeding: Any evidence of bleeding like dis-

proportionate rise in pulse rate and drop in Late Complications
hemoglobin should warn for diagnostic lapa-
roscopy even in absence of any abdominal • Vitamin deficiencies and hair loss.
signs. CECT abdomen may be used as an • Dental problems.
adjunct for relaparoscopy but should not be • Abdominal pain and discomfort.
mandatory and clinical suspicion should alert • Dumping syndrome.
the clinician to have a diagnostic check. Any • Postprandial hypoglycemia.
bleeder should be sutured (over hemostat) and • Loss of bone density.
if no bleeding is seen, check endoscopy intra- • Kidney stones.
operative should be done and bleeder taken • Gallstones.
care of. If still no bleeder is seen and jejeuno- • Gastric remnant distension.
jejunostomy is suspected oversewing the • Marginal ulcers.
anastomosis and if required refashioning the • Stomal Stenosis [12].
anastomosis should be considered.
• Leakage: Another very important complica-
tion is leakage from anastomotic site. Re Conclusion
Laparoscopy with resuturing/refashioning
anastomosis/Gastrostomy drainage with feed- LRYGB offers both benefits and complications,
ing jejeunostomy should be attempted depend- the mechanisms of which are still not fully under-
ing on the time of redo surgery and patient stood. Most clinicians agree that beneficial
general condition. Leakage from Jejeuno- effects outweigh harm [13, 14]. The suggestions
jejunostomy should be dealt with suturing/ that the LRYGB relies solely on mechanical
refashioning with distal feeding jejunostomy restriction and malabsorption are no longer valid.
should be done. In order to achieve positive results after LRYGB,
• Stenosis: Gastrojejunostomy stricture should the harmony of intestinal hormones, bile acids,
be dealt with the removal of triggering factor nerve mechanisms, intestinal microbiota, food
(Smoking) and serial dilatations or refashion- preferences and changes in energy expenditure is
ing. Jejuno-jejunostomy stricture will present essential [15]. Complications can be seen in all
with obstruction or abdominal distension and bariatric surgical methods. However, many stud-
will require refashioning. ies have been conducted in order to diagnose
• Others: Deep Venous Thrombosis and complications early and manage them correctly
Pulmonary embolism should be dealt with after LRYGB.
296 R. Goel et al.
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weight loss and complications of Roux-en-Y gastric
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2. Wittgrove AC, Clark GW, Schubert KR. Laparoscopic
bariatric surgery: sleeve gastrectomy, Roux-en-Y gas-
gastric bypass, Roux en-Y: technique and results in
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One Anastomosis Gastric Bypass
(OAGB)
Hrishikesh Salgaonkar, Alistair Sharples,

Kanagaraj Marimuthu, Vittal Rao,
and Nagammapudur Balaji
One-anastomosis gastric bypass is an attractive anastomosis gastric bypass naming it “mini-

option in the armament of a Bariatric surgeon. A gastric bypass” (MGB). This was mainly because
relatively simple procedure, it has been effective the original technique was described through a
in inducing weight loss and resolution of obesity- mini-laparotomy [2]. In his technique, the gastric
associated comorbidities. Easy technique, shorter pouch was a lesser curvature-based long sleeve
operative times, and low complication rates make starting 2–3 cm distal to the crow’s feet and
it an attractive alternative option, particularly in extending slightly to the left of the “angle of His”
super-obese individuals. While concerns remain proximally. A single ante-colic anastomosis
regarding the long-term safety profile with between the gastric pouch and jejunum, about
regards to biliary reflux, risk of esophagogastric 3–5 cm wide was constructed 180–220 cm distal
malignancies, and marginal ulcer. For the scope to the ligament of Treitz. This distance from the
of this chapter, our focus will be on the advent of ligament of Treitz was modified marginally in
the concept, the surgical technique, and tips and selected cases based on the obesity class, age,
tricks. and dietary preferences.
In order to reduce bile reflux, in 2002 Carbajo
and Caballero proposed a variation to this tech-
Introduction nique wherein a latero-lateral anastomosis was
performed between the gastric pouch and jejunal
The concept of “loop” gastric bypass was first loop, averagely 250–350 cm from the ligament of
introduced by Mason in 1967, which consisted of Treitz. They named the technique “one anastomo-
a gastric bypass with only one anastomosis [1]. sis gastric bypass” (OAGB) or “bypass gastrico
Mason’s suggested a short and horizontal-shaped de una anastomosis” in Spanish (BAGUA) [3].
wide gastric pouch. This configuration exposed Over the years a variety of names like “omega
the esophageal mucosa to caustic bile reflux from loop gastric bypass” (OLGB) or “single anasto-
the jejunal loop. Due to its bile reflux-inducing mosis gastric bypass” (SAGB) have been used to
mechanism, this concept was abandoned quickly. describe the procedure [4, 5]. Finally, in 2013, a
Rutledge in 1997, introduced his version of one group of surgeons proposed the term “mini-
gastric bypass-one anastomosis gastric bypass”
(MGB-OAGB) to standardize the nomenclature
H. Salgaonkar (*) · A. Sharples · K. Marimuthu ·
and reduced the confusion created by multiple
V. Rao · N. Balaji
Department of Bariatric and Upper GI Surgery, names for essentially the same procedure [6].
University Hospitals North Midlands, This nomenclature was later approved by the
Stoke-on-Trent, UK International Federation for the Surgery of
https://doi.org/10.1007/978-981-19-3755-2_43
298 H. Salgaonkar et al.
Obesity and Metabolic disorders (IFSO) MGB- ease, and impaired intellectual capacity which
OAGB task force and recommended that OAGB prevents the patient from understanding the long-
should be the identifier for this procedure in term implications and postoperative care.
future publications [7]. Over the last decade, Preoperative reflux has been found to have an
although the popularity of the procedure is on the increased risk with the development of postoper-
rise particularly in Asia Pacific and Europe ative bile reflux [11] and hence it is the author’s
region, [8] concerns regarding the possibility of opinion that OAGB should be deferred in these
bilio-enteric reflux and its long-term implications groups of patients.
mainly the theoretical risk of gastric and esopha-
geal cancer persists.
Preoperative Assessment
and Work-Up
Indications
Patients should be evaluated by a multidisci-
Suitability for bariatric surgery is based on body plinary team comprising of surgeon, physician,
mass index (BMI) and the presence of comorbid- psychologist/psychiatrist, and nutritionist. These
ity. These indications remain the same for offer- teams should work in close collaboration with the
ing OAGB general practitioners and community healthcare/
social workers. A thorough preoperative psycho-
• BMI of 40 kg/m2 or greater without coexisting logical, nutritional, and medical evaluation
medical problems. including assessment of comorbidities and fitness
• Patients with a BMI greater than or equal to for surgery should be done. Patient education
35 kg/m2 and one or more obesity-related with regards to the lifestyle changes they need to
comorbidities, e.g., type 2 diabetes, hyperten- undergo, what to expect before, during, and after
sion, severe debilitating arthritis, hyperlipid- surgery, nutritional and psychological changes
emia, obstructive sleep apnoea (OSA), postsurgery is paramount. We routinely prescribe
nonalcoholic fatty liver disease (NAFLD), 2 weeks of low-calorie high protein diet preop-
gastroesophageal reflux disease (GERD), etc. eratively. This is particularly helpful to shrink the
• Patients with BMI between 30 and 34.9 kg/m2 liver size and assist during the surgery with liver
with recent onset type 2 diabetes or metabolic retraction.
syndrome also may undergo weight loss sur-
gery, although there is a lack of sufficient data
to demonstrate long-term benefits in such Operative Technique
patients [9, 10].
Operation theater layout—The patient is placed
supine position with split leg (Fig. 1). In bariatric
Contraindications surgery securing patient to the operative table is
of paramount importance with straps at mid-
As OAGB is performed under general anesthesia, thigh levels, to both legs separately and foot
any contraindications for giving general anesthe- support.
sia automatically is a contraindication to proceed Test this preoperatively by placing patient in
with surgery. From a surgical perspective, there anti-Trendelenburg position before starting the
are no absolute contraindications to OAGB, surgery. Both the arms are tucked by the patient
although relative contraindications do exist. side. Compression stockings and pneumatic
These are drug/alcohol dependency, unstable compression devices are applied to both legs
coronary artery disease, end-stage lung disorders, until unless contraindicated. The surgeon stands
severe heart failure, patients receiving active can- in between the legs, camera operator on the right
cer treatment, portal hypertension, Crohn’s dis- side, and another assistant on the left. Standard 5
One Anastomosis Gastric Bypass (OAGB) 299
Instrumentation—Over the years with

advances in instrument technology many types of
nontraumatic bowel graspers, energy devices,
needle holders, suturing devices, liver retractors,
suction-irrigation devices and tools designed for
dissecting the abdominal cavity have been devel-
oped. Based on surgeon preference these can
2nd Assistant vary, important factor when using any device or
instrument is its safety profile, simplicity of use,
!st Assistant cost, easy availability, and reusability.
Abdominal access and technique—Creation of
pneumoperitoneum can be done using a Veress
needle or by direct trocar entry (Optical entry)
Surgeon
and insufflating the abdomen to 12–15 mm of
Hg. The table is then placed in anti-Trendelenburg
position 30–40°. This allows better visualization
Fig. 1 Theater setup and patient position of the stomach and tissue spaces that need to be
dissected. Rest trocars are placed under vision. A
liver retraction device is placed through one of
these port sites, usually substernal to expose the
hiatal, stomach, and surrounding areas.
Always start by performing a general exami-
Liver retractor nation of the peritoneal cavity to exclude any
other pathology, e.g., abdominal wall hernia,
adhesions, etc.
5mm Phase 1—The angle of His and fundal fat pad is
identified. While some surgeons just delineate the
12mm fundal fat pad, others prefer to dissect off the same
to expose the left crus of the diaphragm explicitly in
12 mm
order for optimal positional of the stapling device at
12mm this extremely critical location. Always look out for
a hiatal hernia which is not an uncommon occur-
rence in morbidly obese. If present, dissect the
phreno-esophageal membrane and peri-esophageal
adhesions to reduce the hernia. Post reduction, at
least 2–3 cm of intra-abdominal length of esopha-
gus should be achieved. Hiatal closure is performed
using standard principles and care.
Phase 2—The most important step in OAGB is
creation of a “long gastric pouch” to keep the bile
stream as far away from the esophagus as possible.
Fig. 2 Port placement Identify the crow’s foot and just distal to it, dissect
the gastro-hepatic omentum adjacent to the lesser
curvature to enter the retro-gastric space. Care
trocars technique is used (Fig. 2). While tech- should be taken so that the entry point is always
niques for performing various bariatric proce- distal to the crow’s foot and proximal to the pylo-
dures have a reasonable amount of variation rus. Avoid unnecessary dissection medially along
based upon surgeon preference and training, the the lesser curvature posteriorly, so as to avoid
objectives are relatively uniform. injury to the left gastric artery. Based upon sur-
Fig. 3 Identification of “crow’s feet” and first endo-stapler fire horizontally in distal gastric region perpendicular to the
lesser curvature
geon preference different stapling devices can be

used. Using a 45 mm/3–4 mm stapler the first fire
is performed from the right-side working trocar in
a relatively perpendicular direction to the lesser
curvature (Fig. 3). Any gastric pouch shorter than
9 cm has been correlated with an increased risk of
postoperative duodeno-gastroesophageal reflux.
Lee et al. [12] long pouch also reduces the ten-
sion on the future anastomosis. At this moment the
anesthetist passes a 36–40 Fr bougie under vision
and narrow pouch is created over this. Vertical sec-
tioning is next and using a 60 mm/3–4 mm stapler
introduced through the left working trocar, fired Fig. 4 Tension-free long gastric pouch
from the crotch of the first fire parallel to the lesser
curve and vertically up towards the angle of His. stapler jaw does not injure the spleen or splenic
The endo-stapler is adjusted close to the bougie vessels. Verify complete gastric transection, any
but not very tight. When in doubt ask the anesthe- terminal tissue connections do not hesitate to use
tist to pull back the bougie by a few centimeters an additional endo-staple fire. It is important to
and reinsert to make sure it is not caught in the achieve hemostasis along the gastric staple lines
endo-stapler. After every staple fire, migratory on pouch as well as the remnant stomach, as these
staples if any should be removed. This reduces the areas may become difficult to visualize once you
risk of endo-stapler misfiring. Before every staple perform gastro-jejunal anastomosis. A good gas-
fire, check for posterior wall redundancy and do tric pouch should be long (15–18 cm), narrow,
necessary adjustments. As you progress cranially well vascularized without any torsion. It should be
towards the angle of His, posterior adhesions if easy to bring the pouch caudally without any
any should be dissected. Once close to the angle of undue tension (Fig. 4).
His, connection with the anterior dissection done Phase 2—Reduce the anti-Trendelenburg tilt
at the onset is possible. Make sure to create a wide and if required we can do a slight Trendelenburg
retro-gastric window so as to visualize the left crus so as to help visualize and measure entire small
of diaphragm. Stay well away “1–2 cm” lateral to bowel. The first step is to visualize the ligament of
the esophagogastric junction. This step is Treitz, which is achieved by lifting the gastro-colic
extremely critical to avoid complications namely omentum above the transverse colon. Jejunal
leaks. Also, take care that the tip of the endo- counting is done with atraumatic bowel graspers,
sequentially by grasping and running segments in Phase 3—Using an ultrasonic shear or a dia-
increments of 5–10 cm. Once we reach a point of thermy hook, small apertures are made in the dis-
150–200 cm distally, the assistant grasps the bowel tal gastric pouch and the small bowel (usually
as an indicator. The point varies based upon the about 5 mm). Confirm that we have entered the
patient’s obesity class, BMI, and comorbidities lumen by passing a tip of nontraumatic bowel
profile. In certain s pecific scenarios, this point may grasper into the lumen through the aperture or
be extended beyond 200 cm. Although longer limb aspiration of intraluminal contents. Secure hemo-
lengths can give better weight loss results, it also stasis and rule out any mechanical injury on the
increases the risk of malnutrition and excess posterior or lateral wall. Using a 30 mm or
weight loss, especially beyond 250 cm [11, 13]. It 45 mm/3–4 mm stapler an ante-colic GJ anasto-
is the author’s preference to continue running the mosis is performed. The gastro-enteric opening is
bowel distally to count the entire small bowel upto then closed using 2–0 reabsorbable sutures or
the ileocecal junction, so as to assess the common Stratafix or V-loc continuous closure. The authors
channel (CC) length. Maintaining at least 300– prefer re-enforcing with a second sero-muscular
350 cm of common channel is a prudent strategy. layer (Two-layered technique). During learning
Once the measurement is complete the assis- curve, it may be advisable to perform the anasto-
tant grasps the small bowel and holds it in place. mosis over a gastric bougie by asking the anes-
Based upon surgeon preference if needed we can thetist to pass the same distally into the efferent
put a serosal stitch with vicryl keeping long ends limb. The authors prefer performing a latero-
or encircle the small bowel by a soft rubber drain lateral anastomosis so as to maintain an isoperi-
(e.g., Jaques catheter) through a small opening in staltic pattern of food bolus flow (Fig. 5).
the mesentery. The assistant grasps the drain or Bile reflux is a major criticism of OAGB, and
vicryl stitch ends which helps in fixing the point hence some surgeons prefer adding an “anti-
as well as helps in providing traction during the reflux mechanism” wherein a continuous latero-
gastro-jejunal (GJ) anastomosis. If any difficulty lateral suture between the small bowel loop
or tension while bringing the small bowel loop (along the antimesenteric border) and the staple
towards the gastric pouch should warrant an line of gastric pouch performed. This should be
omental split. done ideally before the GJ anastomosis is done
Fig. 5 Steps of gastro-jejunal anastomosis

performed starting from between the junction uncommon in OAGB [12]. This is mainly due to
of first and second vertical staple firing on the the greater effect of malabsorption, which may be
gastric pouch and 8–10 cm caudally up to the tip a favourable effect in super-obese. The same may
of gastric pouch as described in the “Spanish also lead to theoretically higher risk of nutritional
BAGUA technique” [14]. deficiencies. There is lack of long-term data with
Phase 4—Competency of the anastomosis is regards to nutritional complications. Hence, life-
tested using a leak test “methylene blue” or long follow up is paramount, and in the event of
“pneumatic test” with help of the anesthetist. This excessive weight loss or specific nutritional defi-
can be done through a nasogastric tube or calibra- ciency treatment with additional supplements is
tion tube respectively positioned just proximal to necessary. Unattended, risk of life-threatening
the anastomosis. Visualize all the staple lines and malnutrition, Wernicke encephalopathy, iron defi-
potential sites for bleeding and secure hemostasis ciency anaemia and hypo-albuminemia is high. In
using titanium clips. We routinely do not place cases where despite of active intervention exces-
intra-abdominal drain. All trocars are removed sive weight loss and deficiencies persists, reversal
under vision to rule out any port site bleeding. of OAGB to a RYGB or a sleeve gastrectomy is a
valuable option. The two major criticism of
OAGB are bile reflux and possible risk of cancer.
Postoperative Care Bile reflux – Overall incidence of bile reflux after
OAGB is 1–4%, with a statistical correlation with
As per the ERAS protocol (Early recovery after pouches shorter than 9 cm and presence of pre-
surgery), adequate analgesics and anti-emetics are operative GERD [11]. In symptomatic reflux, the
prescribed. Early mobilization and free fluids initial treatment consists of trial with probiotics
(clear liquid diet) starting initially with 20–30 ml e.g. yogurt, avoiding fatty and high-volume meals
swallows of water are recommended once patient and proton-pump inhibitors (PPI). However, in
is fully awake. Most patients usually tolerate this severe and intractable cases, a reversal or revision
regimen well and are discharged 24h postopera- to RYGB may be considered with a Roux-limb of
tively with specific advice on diet, physical 50 cm or more. Risk of cancer – Potential risk of
activity, medications, and red flag signs. We rou- gastric or esophageal cancer following OAGB is
tinely discharge patients with anti-thrombotic pro- derived from the fact that exposure of GE junction
phylaxis (also given during hospital stay) based on and esophagus to alkaline bile reflux is a risk fac-
the hospital recommendations. The bariatric team tor for Barrett’s esophagus. Till date only 4 cases
is always contactable by telephone for consulta- of gastric cancer have been reported after loop
tion if needed and there is a very low threshold to gastric bypass (not OAGB), 3 of which were in
call the patient back for evaluation if any issues. the remnant stomach which are basically not
related to OAGB. Only 1 case of cancer at gastric
cardia following OAGB has been published. In
Complications conclusion definitive correlation of gastric cancer
to OAGB has not yet been proven. The OAGB
Although there is paucity of evidence from ran- technique of Carbajo is an excellent modification
domised control trials, early and late complication to decrease or eliminate bile reflux after OAGB.
rates following OAGB are acceptable and compa-
rable [7]. Complications such as staple line bleed-
ing, anastomotic leak, stricture, marginal ulcer, Conclusion
surgical site infections, port site hernia, conver-
sion rates, diarrhoea, dumping syndrome etc are OAGB is one of the simpler bariatric procedure
similar to any other bariatric procedure. Risk of with a shorter learning curve and hence is an
internal hernia is lower in OAGB compared to important addition to the armament of any bariat-
RYGB, as also is the occurrence of small bowel ric surgeon. It provides durable weight loss and
obstruction. Inadequate weight loss is relatively metabolic results with lower perioperative mor-
bidity and hence holds promise for the future. although rare have been seen and dealt with in
Proper patient selection and standardization of addition to rare twists seen with the long gastric
technique are paramount so that in future OAGB pouch. These are to be borne in mind when the
forms an equivalent alternative to routinely per- technique is adopted and advised to patients.
formed bariatric and metabolic surgery.
References
Tips
1. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin
North Am. 1967;47(6):1345–51.
• Secure the patient well to the operating table, 2. Rutledge R. The mini-gastric bypass: experience with
this allows us to maneuver the operating table the first 1, 274 cases. Obes Surg. 2001;11(3):276–80.
to suit us when we operate in the supra or 3. Carbajo M, García-Caballero M, Toledano M,
infra-colic compartments. Assess before et al. Oneanastomosis gastric bypass by laparos-
copy: results of the first 209 patients. Obes Surg.
scrubbing for the case. 2005;15(3):398–404.
• Have a good team assisting during the surgery. 4. Lee WJ, Lin YH. Single-anastomosis gastric bypass
A team well versed with the procedure reduces (SAGB): appraisal of clinical evidence. Obes Surg.
operative times and complications. 2014;24(10):1749–56.
5. Chevallier JM, Arman GA, Guenzi M, et al. One
• Do not hesitate to introduce additional trocars, thousand single anastomosis (omega loop) gastric
struggling to reach the area of interest may bypasses to treat morbid obesity in a 7-year period:
lead to unnecessary complications. outcomes show few complications and good efficacy.
• Take care while manipulating the calibration Obes Surg. 2015;25(6):951–8.
6. Musella M, Milone M. Still "controversies" about the
tube or bougie, avoid any forceful intervention mini gastric bypass? Obes Surg. 2014;24(4):643–4.
while inserting the same. 7. De Luca M, Tie T, Ooi G, et al. Mini gastric bypass-
• Always keep a long gastric pouch. one anastomosis gastric bypass (MGB-OAGB)-IFSO
• Always measure the entire bowel length position statement. Obes Surg. 2018;28:1188–206.
8. Angrisani L, et al. Bariatric surgery and Endoluminal
namely the Biliopancreatic limb and the procedures: IFSO worldwide survey 2014. Obes Surg.
common channel. Maintain at least 300–
2017;27(9):2279–89.
350 cm of common channel. 9. Dimitrov DV, Ivanov V, Atanasova M. Advantages of
bariatric medicine for individualized prevention and
treatments: multidisciplinary approach in body cul-
ture and prevention of obesity and diabetes. EPMA J.
2011;2(3):271–6.
Disclosure 10. Mancini MC. Bariatric surgery--an update for the
endocrinologist. Arq Bras Endocrinol Metabol.
2014;58(9):875–88.
Author’s institutional practice The primary bariat- 11. Musella M, Susa A, Manno E, De Luca M, Greco
ric procedure of choice in the institution of the F, Raffaelli M, et al. Complications following
author is a Roux Y Gastric bypass (RYGB) with the mini/one anastomosis gastric bypass (MGB/
the OAGB being reserved for patients with BMI > OAGB): a multi-institutional survey on 2678 patients
with a mid-term (5 years) follow-up. Obes Surg.
55 or 60. However all patients are consented for a 2017;27:2956–67.
OAGB as a backup procedure if there are any tech- 12. Lee WJ, Lee YC, Ser KH, Chen SC, Chen JC, Su YH,
nical factors that may hinder the safe performance et al. Revisional surgery for laparoscopic minigastric
of a RYGB. It is also to be noted that OAGB is an bypass. Surg Obes Relat Dis. 2011;7:486–91.
13. Lee WJ, Wang W, Lee YC, Huang MT, Ser KH, Chen
equally safe and effective procedure with fre- JC, et al. Laparoscopic mini-gastric bypass: experi-
quently reported weight loss and co-morbidity ence with tailored bypass limb according to body
resolution being better than a RYGB. However, in weight. Obes Surg. 2008;18:294–9.
spite of being a simpler procedure, the author’s 14. Carbajo MA, Luque-de-León E, Valdez-Hashimoto
JF, Ruiz-Tovar J. Anti-reflux one-anastomosis gastric
institution has dealt with complications related to bypass (OAGB)—(Spanish BAGUA): step-by-step
troublesome gastric reflux, bile reflux, malabsorp- technique, rationale and bowel lengths. In: Deitel M,
tion and excess weight loss needing conversion to editor. Essentials of mini – one anastomosis gastric
a RYGB. Internal hernias (Peterson’s hernia) bypass. Cham: Springer; 2018.
Part XI
Hepatobiliary Surgery: Gallbladder
Elective Cholecystectomy
Arnel Abatayo
Introduction scopic cholecystectomy (LC). This is because of

its associated advantages over conventional open
Cholecystectomy is one of the most commonly technique that includes less postoperative pain,
performed abdominal surgery to date. In the last better cosmesis, and shorter hospital stays [2–8].
few decades, it is increasingly performed laparo- However, despite the advances in technology, the
scopically, even with third-world countries in complications associated with laparoscopic cho-
Asia. In Mongolia for example, where there are lecystectomy remain the same. It is therefore nec-
limited resources, they have found a 62% increase essary for surgeons to be familiar with the basic
in laparoscopic cholecystectomy being performed principles and techniques in performing a safe
for 9 years since 2005 [1]. At present, the “gold and efficient procedure. Below is the anatomy of
standard” in gallbladder (GB) surgery is laparo- Gallbladder (Fig. 1).
A. Abatayo (*)
Department of Surgery, Chong Hua Hospital
Mandaue, Cebu, Philippines

https://doi.org/10.1007/978-981-19-3755-2_44
308 A. Abatayo
Fig. 1 Gallbladder
anatomy
Gallbladder retracted
upwards
Cystic artery Hepatic duct
Hepatic artery
Cystic duct
Portal vein
Indications • Untreated coagulopathy.

• Cholecystoenteric fistulas.
The indications for laparoscopic cholecystectomy • Previous abdominal operations.
are the same as for open cholecystectomy [9]: • End-stage cirrhosis of the liver with portal
hypertension.
• Symptomatic GB stones. • Suspected or known gallbladder cancer.
• Asymptomatic GB stones in patients with cer-
tain conditions (elderly patients with diabetes, However, some would consider these as rela-
patients with increased risk for GB cancer, tive contraindications nowadays because of sur-
and individuals isolated from medical care for geon experience and judgment. Absolute
extended periods of time). contraindications of LC are usually related to the
• Acalculous cholecystitis. anesthetic risks.
• Gallbladder polyps >0.8 cm or lesser in symp-
tomatic patients.
• Porcelain gallbladder. Preoperative Assessment
Laboratory Work-Up
Contraindications
The basic blood work-up needed in evaluating
The contraindications of laparoscopic cholecys- GB disease generally includes complete blood
tectomy include the following: count and liver enzymes such as SGPT,
Alkaline Phosphatase, and Bilirubin levels.
• Generalized peritonitis. Uncomplicated GB disease generally shows nor-
• Septic shock from cholangitis. mal or unremarkable results. However, if any of
• Severe acute pancreatitis. these blood tests are elevated, a more compli-
Elective Cholecystectomy 309
cated disease should be considered, such as CT Scan

acute cholecystitis, or in cases where bile duct
obstruction (e.g., Mirizzi syndrome, CBD stone) Contrast-enhanced computed tomography (CT)
may be present. A study using multivariate anal- may have a limited role in gallbladder disease.
ysis showed that neutrophil count was the only It is generally used to evaluate other organ sys-
independent predictor of acute cholecystitis tems to rule out other conditions. However, CT
[10]. Also, the role of procalcitonin in determin- is the imaging of choice in determining an
ing disease severity has been discussed in some emphysematous GB. It can accurately assess
literature especially with regards to inflamma- the presence of gas within the gallbladder wall
tory response; however, its value in determining or lumen, indicative of GB emphysema, which
GB disease severity still needs further investiga- appears clearly as a hypodense area on CT [13].
tion. Aside from assessing for GB disease sever-
ity, it is important to evaluate for the presence of
other related conditions. Serum amylase and When to Do Surgery?
lipase may be requested to rule out the presence
of pancreatitis, especially in a patient complain- The timing of surgery depends on the overall
ing of severe epigastric pain. condition of the patient. Generally, patients who
are well with no signs of complicated GB dis-
ease can be scheduled electively. Otherwise, for
Imaging those with more complicated GB disease, such
as acute cholecystitis, an emergent or urgent sur-
Ultrasonography gery within 72 h is advised which is discussed in
Despite the newer and more advanced imaging the section of emergency laparoscopic surgery.
modality now available, ultrasonography (US)
remains the first-line imaging modality in the
evaluation of gallbladder disease. It is cost- Operating theater Setup
effective, less invasive, widely available, and
easy to use [11]. A comparison among different Below are the operating room setup (Fig. 2) and
diagnostic imaging for acute cholecystitis port placement (Fig. 3).
reported that US has 81% sensitivity (95% CI:
0.75–0.87) and 83% specificity (95% CI: 0.74–
0.89) [12].
MRI/MRCP
Magnetic Resonance Imaging (MRI) generally

gives a better picture of the GB compared to
US. It is the recommended imaging modality Surgeon
next to US, especially in cases where US report Assistant
is inconclusive. The diagnostic yield of MRI for
acute cholecystitis showed an 85% sensitivity Camera man
(95% CI: 0.66–0.95) and 81% specificity (95%
CI: 0.69–0.90) based on a 2012 meta-analysis
[12]. One advantage of MRCP is that it can
define the anatomy of the biliary system, which
makes it very useful in assessing other related
conditions. Fig. 2 Operating room setup
310 A. Abatayo
Port Placement Standard Technique
1. Retract the GB fundus supero-laterally, expos-

ing the infundibulo-cystic junction (IC) and
hepatocystic triangle.
2. Open the peritoneal membrane around the IC
junction, anteriorly and posteriorly, extending
towards the GB body. This will open the
Hepatocystic triangle.
3. Continue dissecting and clear the hepatocystic
triangle to expose the cystic artery, cystic duct,
and cystic plate. By doing this, you have already
achieved the “critical view of safety” (Fig. 4).
4. Ligate the cystic artery using clips/suture and
cut. This step sometimes helps lengthen the
cystic duct, especially in cases where the IC
junction is close to the CBD.
5. Intraoperative assessment of the biliary tree
using intraoperative cholangiogram may be
1 2 3
6 7 8
Fig. 4 Steps in doing laparoscopic cholecystectomy

Elective Cholecystectomy 311
selectively done depending on surgeon prefer- heavy objects may be prudent for a few weeks
ence or when clinically indicated during this in cases where the umbilical incision is enlarged
time. during specimen extraction.
6. Ligate the cystic duct using clips/suture and
cut.
7. Completely remove the remaining part of the Laparoscopic Cholecystectomy
GB from the liver bed. in Obesity
8. Extract the GB through the umbilical port.
Another option is to extract the GB through Obesity used to be considered a relative contraindi-
the epigastric region if a larger port was used. cation to LC due to the technical difficulties associ-
ated with this condition. This resulted in a higher
morbidity and mortality as well as higher rate of
Complications and Management conversion [16]. However, due to advances in tech-
nology, improved instrumentation and increase in
Laparoscopic cholecystectomy is generally a surgical experience, the practice of LC has become
safe procedure, especially in uncomplicated safer and more feasible among obese patients [17–
cases. However, in rare situations, complica- 19]. Majority of the issues encountered in an obese
tions occur due to several factors such as unusual patient are due the increase in abdominal wall
anatomy, presence of inflammation and adhe- thickness as well as increase in intra-abdominal fat
sions, and many others. Intraoperative compli- resulting in a cramped operative field. Here are a
cations include vascular injuries, bowel few tips that can help you achieve a safe and suc-
perforation, mesenteric injuries, and bile duct cessful LC in this group of patients.
injuries which are usually managed successfully
through laparoscopy. Although other serious 1. Use of longer trocars, laparoscope, and
complications have been reported, they will not instruments.
be discussed here since they are beyond the 2. When inserting trocars, it is important to
scope of this section. angulate its direction towards the area of the
gallbladder. This is because obese patients
naturally have thicker abdominal wall restrict-
Postoperative Care ing its movement.
3. In situations where long laparoscope and
Majority of patients can start general liquids instruments are not available. Umbilical tro-
once fully awake and their diet progressed as car can be inserted at the supraumbilical
tolerated. A low-fat diet in the early postopera- region to keep it close to the operative site.
tive period is advised but may vary widely 4. Judicious use of additional trocars to facilitate
depending on the surgeon’s experience. Some retraction of the liver and the omentum. This can
evidence demonstrated that some post-chole- improve the operative field and provide better
cystectomy patients experience food intoler- access to the GB and other critical structures.
ance to fatty food [14, 15]. Pain in the umbilical
incision can easily be managed with oral anal-
gesics and generally resolves after 2–3 days. References
There are patients who may experience pain in
the right shoulder which is due to the irritation 1. Expansion of Laparoscopic Cholecystectomy in a
Resource Limited Setting, Mongolia: a 9-year cross-
of CO2 to the diaphragm, but this usually sectional retrospective review.
improves within 24h post-op. Patients may 2. Soper NJ, Stockmann PT, Dunnegan DL, Ashley
freely ambulate with no restrictions. In certain SW. Laparoscopic cholecystectomy. The new ‘gold
situations however the limitation of lifting standard’? Arch Surg. 1992;127:917.
312 A. Abatayo
3. Schirmer BD, Edge SB, Dix J, et al. Laparoscopic of acute cholangitis (with videos). J Hepatobiliary
cholecystectomy. Treatment of choice for symptom- Pancreat Sci. 2018;25(1):17–30. https://doi.
atic cholelithiasis. Ann Surg. 1991;213:665–7. org/10.1002/jhbp.512.
4. Wiesen SM, Unger SW, Barkin JS, et al. Laparoscopic 12. Kiewiet JJ, Leeuwenburgh MM, Bipat S, Bossuyt
cholecystectomy: the procedure of choice for acute PM, Stoker J, Fuks D, Mouly C, Robert B, Hajji H,
cholecystitis. Am J Gastroenterol. 1993;88:334. Yzet T, Regimbeau J-M, Boermeester MA. A system-
5. Wilson RG, Macintyre IM, Nixon SJ, et al. atic review and meta-analysis of diagnostic perfor-
Laparoscopic cholecystectomy as a safe and effec- mance of imaging in acute cholecystitis. Radiology.
tive treatment for severe acute cholecystitis. BMJ. 2012;264:708–20.
1992;305:394. 13. Patel NB, Oto A, Thomas S. Multidetector CT of emer-
6. Rattner DW, Ferguson C, Warshaw AL. Factors gent biliary pathologic conditions. Radiographics.
associated with successful laparoscopic cholecys-
2013;33:1867–88.
tectomy for acute cholecystitis. Ann Surg. 1993; 14. Fisher M, Spilias DC, Tong LK. Diarrhoea after lapa-
217:233. roscopic cholecystectomy: incidence and main deter-
7. Johansson M, Thune A, Nelvin L, et al. Randomized minants. ANZ J Surg. 2008;78:482–6.
clinical trial of open versus laparoscopic cholecystec- 15. Johnson AG. Gallstones and flatulent dyspepsia: cause
tomy in the treatment of acute cholecystitis. Br J Surg. or coincidence? Postgrad Med J. 1971;47:767–72.
2005;92:44. 16. Liu CL, Fan ST, Lai EC, Lo CM, Chu KM. Factors
8. Yamashita Y, Takada T, Kawarada Y, et al. Surgical affecting conversion of laparoscopic cholecystectomy
treatment of patients with acute cholecystitis: to open surgery. Arch Surg. 1996;131:98–101.
Tokyo guidelines. J Hepato-Biliary-Pancreat Surg. 17. Simopoulos C, Polychronidis A, Botaitis S, Perente
2007;14:91. S, Pitiakoudis M. Laparoscopic cholecystectomy in
9. NIH releases consensus statement on gallstones. bile obese patients. Obes Surg. 2005;15:243–6.
duct stones and laparoscopic cholecystectomy. Am 18. Ammori BJ, Vezakis A, Davides D, Martin IG,
Fam Physician. 1992;46:1571–4. Larvin M, McMahon MJ. Laparoscopic cholecys-
10. Naidu K, Beenen E, Gananadha S, Mosse C. The tectomy in morbidly obese patients. Surg Endosc.
yield of fever, inflammatory markers and ultrasound 2001;15:1336–9.
in the diagnosis of acute cholecystitis: a valida- 19. Paajanen H, Kakela P, Suuronen S, Paajanen J,
tion of the 2013 Tokyo guidelines. World J Surg. Juvonen P, Pihlajamaki J. Impact of obesity and asso-
2016;40:2892–7. ciated diseases on outcome after laparoscopic cho-
11. Kiriyama S, Kozaka K, Takada T, et al. Tokyo guide- lecystectomy. Surg Laparosc Endosc Percutan Tech.
lines 2018: diagnostic criteria and severity grading 2012;22:509–13.
Part XII
Hepatobiliary Surgery: Common Bile Duct
Stones
Laparoscopic Choledochotomy
for Bile Duct Stones
Nguyen Hoang Bac, Pham Minh Hai,

and Le Quan Anh Tuan
Introduction • Gallstones with concomitant CBD stones.

• CBD stones detected during cholecystectomy.
Laparoscopic common bile duct exploration was • CBD stones that failed to endoscopic approach
first reported in the early 90′. Although this pro- (inaccessibility of the scope, large CBD
cedure has proved beneficial, the widespread stones, multiple CBD stones).
adoption of laparoscopic common bile duct • Multiple primary CBD stones and intrahepatic
exploration is limited because of the technical stones.
complex, the need for specialized instruments
(choledochoscope), and limited exposure and Laparoscopic choledochotomy is recom-
training of the surgical team to LCBDE. mended for patients with CBDs diameter more
Most of CBD stones can be managed by than 7 mm to reduce risk of postoperative stric-
ERCP. LCBDE is mostly performed in patients ture [1].
with concomitant gallstones and CBD stones.
Procedure
Patient Selection
perating Room Setup, Patient
O
Laparoscopic choledochotomy (LCD) is indi- Positioning, and Setting
cated for: Surgical Team
Patient is placed in supine reverse Trendelenburg

N. H. Bac position. The arms should be tucked at the
Department of Surgery, University of Medicine and
Pharmacy, Ho Chi Minh city, Vietnam patient’s sides.
10 mm laparoscope of 30° or 45° is used.
P. M. Hai
Department of Hepatobiliary and Pancreatic Surgery, Operating room setup is as in Fig. 1.
University Medical Center, Ho Chi Minh city, Vietnam
L. Q. A. Tuan (*)
Department of Surgery, University of Medicine and Technique
Pharmacy, Ho Chi Minh city, Vietnam
Department of Hepatobiliary and Pancreatic Surgery, Trocar Placement
University Medical Center, Ho Chi Minh city, Vietnam Trocar sites are as in (Fig. 2).
e-mail: tuan.lqa@umc.edu.vn

https://doi.org/10.1007/978-981-19-3755-2_45
316 N. H. Bac et al.
Fig. 3 crossing vessels on CBD anterior wall
Fig. 1 OR setup
Fig. 4 Choledochoscopy
essential to avoid late stricture of CBD due to

thermal injury. We often use needle tip electro-
cautery as in Fig. 3. Scissors without cautery is
an alternative choice. Stay sutures may facilitate
Fig. 2 Trocar position CBD exposure for opening. Bile culture should
be done when necessary.
Choledochotomy
First, hepatoduodenal ligament is exposed. CBD xploration of Bile Ducts and Stone
E
is the most lateral and superficial tubular struc- Removal
ture in hepatoduodenal ligament. It is recom- After choledochotomy, small stones can be washed
mended that we should clear fat tissue to expose out using an irrigator or flushing water through a
anterior CBD wall. If the location of CBD is not rubber catheter. High pressure during irrigation
clear, aspiration of bile by a narrow-gauge needle should be avoided in case of cholangitis.
may help. A longitudinal incision of 1–2 cm is Choledochoscope is very useful to inspect
made on the anterior CBD wall. Limitation of the CBD and intrahepatic bile ducts for stones
using surgical energy when opening the CBD is and stricture (Fig. 4). The choledochoscope
Laparoscopic Choledochotomy for Bile Duct Stones 317
Fig. 5 Stones extraction by forceps
Stone forceps can be applied through 5 mm

epigastric opening after removing the trocar to
extract CBD stones as in Fig. 5. This modifica-
tion facilitates the extraction of CBD stones espe-
cially large stones or multiple stones which is
more common in Asia. Stones extracted are
placed in a plastic bag. Gas loss when using stone
forceps is insignificant.
Fig. 6 Primary closure of CBD Closure of CBD

Closure of CBD incision can be done with or
without biliary drainage. CBD closure without
should be introduced through a plastic trocar biliary drainage is called primary closure. Biliary
located at the epigastric region, above the drainage can be performed with T-tube (external
opening of the CBD to minimize excessive
drainage) or internal stent (internal drainage).
angulation of the choledochoscope during With regard to internal stent placement, a subse-
manipulation. When exploration demonstrates quent endoscopic session is required to remove
stones, basket or balloon catheter will be used to it. T-tube placement provides a T-tube tract
extract stones. In case of large or impacted through which postoperative percutaneous explo-
stones, fragmentation is necessary. Electro- ration of the bile ducts or residual stone manage-
hydraulic lithotripsy or laser lithotripsy can be ment by choledochoscopy is enabled.
used. We prefer to use electro-hydrolic litho- Primary closure: There is evidence that this
tripsy for fragmentation of bile duct stones technique has benefits as compared to biliary
because it is faster and less expensive compared drainage such as reducing hospital stay, operating
to laser. Fragments will be removed by basket or time, and overall cost. Primary closure is indi-
balloon or flushing via a plastic catheter. With cated in selected patients without acute cholangi-
respect to acute cholangitis, there is higher risk tis, without distal CBD obstruction, and complete
of hemobilia when performing multiple litho- clearance of bile duct stones [2].
tripsy. Hence, we should only address stones Suturing in a continuous or interrupted fash-
that cause obstruction. Residual stones should ion with absorbable 3.0 or 4.0 suture is usually
be removed via T-tube tract after 3–4 weeks by used for primary closure (Fig. 6). After that, a
percutaneous cholangioscopy. white gauze is used to inspect bile leak.
318 N. H. Bac et al.
Fig. 7 Closure of CBD around T-tube
T-tube placement: A suitable T-tube size is Late stricture of CBD may occur and less than
selected according to the size of the 1%, mostly because of inappropriate closure
CBD. Suturing in a continuous or interrupted technique or choledochotomy in a CBD less than
fashion with absorbable 3.0 or 4.0 suture is 7 mm.
performed around the T-tube (Fig. 7). Flushing
water through T-tube helps detect a leak that
needs to be reinforced. Summary
rainage and Closure of Trocar Sites

D Laparoscopic choledochotomy is feasible and
A subhepatic drain is routinely placed and usu- safe. Complication rate is low. Complications are
ally removed after 2–3 days if there is no bile usually mild and self-limited. Appropriate indi-
leak. cation of laparoscopic choledochotomy is
All trocar sites are closed. important.
Complications and Management References
Bile leak rate was reported around 5–7% [2]. Bile 1. Zerey M, Haggerty S, Richardson W, Santos B, Fanelli
R, Brunt LM, et al. Laparoscopic common bile duct
leak is usually mild and self-limited. exploration. Surg Endosc. 2018;32(6):2603–12.
Complications specific to primary closure are 2. Lambour A, Santos BF. Common bile duct explora-
persistent cholangitis or biliary obstruction. This tion. 2020.
happens when there are retained stones or distal
obstruction of the CBD or ascending acute
cholangitis.
Part XIII
Hepatobiliary Surgery: Liver
Hepatic Cyst/Abscess
Rakesh Kumar Gupta
Introduction There has been a significant improvement in

diagnosis, treatment, and outcome of these
Hepatic cysts are common, occurring in at least hepatic lesions.
2–7% of the population, and are typically discov-
ered incidentally with the frequent use of ultraso- Congenital Cyst
nography and computed tomography. Only about • Presentation: They are usually asymptomatic.
16% of such cysts are symptomatic [1]. They They can cause right upper quadrant pain due
may be either congenital or acquired. The more to stretching of Glisson’s capsule and bloating
common congenital variety may represent mal- if large due to pressure effect. If very large,
formed bile ducts while the acquired type of they may be palpable abdominally. Acute
hepatic cyst usually arises as sequelae of inflam- abdominal pain may occur due to hemorrhage
mation, trauma or parasitic disease, and some- in cyst or its rupture. Sometimes they may
times neoplastic disease [2]. cause jaundice due to compression effect.
• Investigations: Ultrasound, CT scanning, and
Classification of cystic liver lesions according to etiology MRI can show cyst anatomy. LFT may be
Congenital slightly abnormal.
• Ductal (dilatation of intrahepatic duct) • Treatment: Options include watchful monitor-
– Ductal cyst
ing if asymptomatic and aspiration/sclerother-
– Caroli’s disease(cystic dilatation of
intrahepatic bile ducts) apy if symptomatic.Laparoscopic/open
• Parenchymal (solitary or polycystic) fenestration may be effective in certain cases.
Acquired Liver transplantation is occasionally needed in
• Infectious case of polycystic liver disease or Caroli’s dis-
– Bacterial—Pyogenic liver abscess ease with liver failure [3].
– Parasitic—Hydatid cyst, amoebic liver
abscess
• Traumatic
• Neoplastic (biliary cystadenoma, Neoplastic Cysts
cystadenocarcinoma) • Presentation: usually asymptomatic or vague
symptoms including bloating, nausea, and
fullness can occur. Abdominal pain and biliary
obstruction can result as they enlarge.
R. K. Gupta (*)
Department of Surgery, B.P. Koirala Institute of • Investigation: LFT may be normal.
Health Sciences, Dharan, Nepal Carbohydrate antigen (CA)—19–9 may be

https://doi.org/10.1007/978-981-19-3755-2_46
322 R. K. Gupta
raised. Typical pattern may be seen on cytic anemia may be present. LFT may be
CT-scan. deranged (raised transaminase, raised alkaline
• Treatment: The definitive treatment is com- phosphatase, raised bilirubin, low albumin).
plete surgical resection. Blood culture will be positive in 50% of cases
of PLA [9]. Stool may contain cysts or tropho-
zoites of E. histolytica in ALA. Serology will
Liver Abscess be helpful in ALA. Chest x-ray may reveal
• Liver abscesses are caused by bacterial (pyo- raised right hemidiaphragm, atelectasis, or
genic abscess), parasitic (amoebic abscess), or pleural effusion. Ultrasonography can show
fungal organisms. In developed countries pyo- abscess (usually single central location in
genic abscesses are the most common but ALA, multiple peripheral location in PLA).
worldwide, amoebic abscesses are the most CT scan is good for detecting small abscesses
common [4]. as well as for detecting the intra-abdominal
• Pyogenic liver abscesses(PLA) are usually cause.
multiple but may be single too, affecting right • Treatment: Most of the cases of liver abscesses
lobe of liver in 74% cases [5]. Most are sec- are managed by either antibiotics alone or
ondary to infection originating in the abdo- combination of antibiotics and drainage
men. It may be iatrogenic secondary to liver guided by ultrasonography or CT. Percutaneous
biopsy or a blocked biliary stent. Bacterial Catheter Drainage (PCD) is more effective
endocarditis and dental infection are other than Percutaneous Needle Aspiration (PNA)
causes. It is more common in immunocom- because it facilitates a higher success rate,
promised. It can be a complication of umbili- reduces the time required to achieve clinical
cal vein catheterization in infants. It tends to relief, and supports a 50% reduction in abscess
be polymicrobial. Organisms are usually of cavity size [10]. The combination of third-
bowel origin. Klebsiella pneumoniae has generation cephalosporin and metronidazole
emerged as the most common organism [6]. is the first-line choice of antibiotics in
Other organisms include E. coli, Bacteroid PLA. Treatment may be needed for upto 12
species, enterococci, streptococci, and weeks and should be guided by the clinical
staphylococci. picture, culture, and radiological evidence.
• Amoebic liver abscesses (ALA), caused by Metronidazole is the treatment of choice in
Entamoeba histolyticais usually single, com- ALA. Use of percutaneous drainage has
mon in tropical and subtropical areas and steadily increased whereas the use of surgical
more likely if there is poor sanitation and drainage has declined [11]. Surgery is needed
overcrowding. Transmission is via feco-oral if the abscess has ruptured or if there is known
route. Amoebae invade intestinal mucosa and pathology such as appendicitis.
gain access to portal venous system. It affects
right lobe in 80% cases [7].
• Presentation: Multiple abscesses tend to pres- Hydatid Cysts
ent more acutely while single ones are more • Aetiopathogenesis: It is caused by infection
indolent. Patients usually present with right with metacystode (larval stage) of
upper quadrant pain which may refer to the Echinococcus tapeworms (E. granulosus and
right shoulder, associated with swinging fever, E. multilocularis). Canine, carnivores such as
night sweats, nausea, vomiting, anorexia, and dogs, and wolves act as definitive hosts where
weight loss. Patients may have cough and dys- adult form of parasites live and sexual cycle
pnea due to diaphragmatic irritation. Jaundice occurs. They give eggs which are passed into
may be present in 6–29% of cases [8]. feces of these hosts. These eggs are ingested
Examination may reveal tender hepatomegaly. by herbivores such as sheep, an intermediate
• Investigation: Total leucocyte count and ESR host. These eggs are turned into larval stage
will be raised. Mild normochromic normo- (child form). Herbivores are intermediate
Hepatic Cyst/Abscess 323
hosts because they are eaten by the definitive When a cyst is formed, this will produce pres-
hosts. This is how cycle of parasitic zoonoses sure symptoms most commonly as the right
completes. Human are not supposed to come upper abdominal heaviness or pain [14].
in between these two hosts. But if acciden- Hepatomegaly may be present. If cyst becomes
tally, human ingest these eggs by ingestion of so large, it may produce portal hypertension
food/water contaminated with eggs or through and obstructive jaundice. Sometimes acute
close contact with infected dogs, human acts abdominal pain may occur and this is because
as intermediate host and is a dead end because of complications (such as perforation, infec-
they are not further eaten up by carnivores. In tion), not just because of cyst formation. Very
humans the eggs reach small intestine, invade rarely anaphylaxis can also occur following
the intestinal wall with three pairs of hooks perforation.
and reach portal vein. Since right portal branch • Investigation: There will be eosinophilia,
is small in length and course is relatively slightly deranged LFT. Serological test is of
straight, and mostly going to the right upper use for diagnosis.ELISA (Enzyme-linked
segments of liver. That is why most common Immunosorbent assay) has sensitivity above
site of hydatid cyst in liver is segment 7/8. 90% and is useful in mass-scale screening.
Larvae that escape hepatic filtering are carried The counter-immunoelectrophoresis has the
to the lung. From the lung, larvae may dis- highest specificity (100%) and high sensitivity
seminate to other distant body parts such as (80–90%). CASONI test has been used most
brain, bone, spleen, and kidney. frequently in the past but is at present consid-
• Initially, when eggs attach to capillary in liver, ered only of historical importance because of
they proliferate and are active. But as immu- low sensitivity. The sensitivity and specificity
nity starts fighting with these eggs, they may of ELISA are highly dependent on the method
become dead. Hence, the fate of eggs is deter- of antigen preparation, and cross-reactions
mined by immunity [12]. Larvae that escape with other helminthic diseases occur if crude
the host’s defense, develop into small cysts antigen is used. Purified fraction may yield
surrounded by a fibrous capsule. These cysts high sensitivity and specificity [15].
grow at a rate of 1–3 cm/year and may remain Ultrasound is the imaging modality of choice
undetected for years [13]. Thus, they can for diagnosis. CT and MRI are modalities of
reach very large sizes before they become choice for number, site, and identification of
clinically evident. A cyst in liver is composed complications. CT is better than MRI to look
of three layers: for calcification while MRI is better to look
–– Adventia (pericyst): consists of com- for biliary involvement. Indirect signs of bili-
pressed liver parenchyma and fibrous tis- ary communication are deformed cyst,
sue induced by expanding parasitic cyst. Crampledhydatid membrane, dilatation of
–– Laminated membrane (ectocyst): is elastic biliary tree, close contact between cyst and
white covering, easily separable from the biliary branch, interrupted calcified wall, and
adventitia. fluid-fat level in the cyst. WHO has developed
–– Germinal epithelium (endocyst): is a single a standardized classification system [16], orig-
layer of cells lining the inner aspect of the inally developed by Gharbi and colleagues in
cyst and is the only living component, 1981, and is currently the screening method of
being responsible for the formation of choice (Table 1).
other layers as well as hydatid fluid and • Treatment: All of the four modalities (chemo-
brood capsules within the cyst. In some therapy, interventional radiology, endoscopic
cysts, laminated membrane may eventually procedure, and surgery) have a role in its man-
disintegrate and brood capsules are freed agement. The choice of an optimal treatment
and grow into daughter cysts. should be carefully assessed in each case [17].
• Presentation: There is usually no symptom in • Chemotherapy (albendazole 400 mg twice a
acute stage when eggs just infect the liver. day): It is useful in type 1 and 3a WHO cysts,
324 R. K. Gupta
Table 1 Classification of hydatid cyst of liver

WHO-2001 Gharbi-1981 Description Stage
CE1 Type I Unilocular, unechoic, Active
Hydatid sand, snow storm
CE2 Type III Multi-septated, rosette like, honeycomb cyst, spoke Active
wheel sign
CE3A Type II Cyst with detached membrane(water lily sign) Transitional
CE3B Type III Cyst with daughter cysts in solid matrix Transitional
CE4 Type IV Cyst with heterogeneously/hyper-echoic contents. No Inactive
daughter cysts, ball of wool sign
CE5 Type V Solid cyst with calcified wall Inactive
where the cyst is single, less than 5 cm. The catheter at the end of the procedure and
rationale is that the drug can penetrate the cyst drained for 24 h.
wall. But when the cyst has predominant solid –– D-PAI (Double Puncture Aspiration
component or daughter cysts, the drug may Injection): It is used for univesicular cyst.
not penetrate even after long-term use of che- With ultrasound guidance, fine needle
motherapy and drugs should not be used. drainage of cyst was performed, 95% alco-
However, it can be used as adjuvant or neoad- hol was injected, and left in situ partly fill-
juvant to PAIR or surgery to prevent recur- ing the cyst cavity. The same procedure is
rence. Four days to 1 month of preoperative performed 3 days later [19].
therapy and 4–6 months postoperative therapy –– PEVAC (Percutaneous Evacuation of cyst
with albendazole are recommended. As per contents): It is used for multivesicular
WHO, 3 months preoperative therapy is most cysts. It involves the following steps:
effective. It is of no use in calcified dead cyst. ultrasound-guided cyst puncture and aspi-
• Interventional radiology: ration of cyst fluid to release intracystic
pressure and thereby avoid leakage; inser-
Treatment options are tion of a large bore catheter; aspiration and
–– PAIR (Percutaneous Aspiration Injection evacuation of daughter and endocyst by
Reaspiration): injection and reaspiration of isotonic
Indications are [18]: saline; cystography; injection of scolicidal
only if no cystobiliary fistula is present;
• CE1, CE2, CE3. external drainage of cystobiliary fistula
• Multiple cysts if accessible to puncture. combined with sphincterotomy; and
• Infected cyst. catheter removal after complete cyst

• Patients who fail to respond to medical collapse and closure of cystobiliary

management. fistula [20].
• Patients in whom surgery is contraindicated.
• Patients who relapse after surgery.
Complications of Interventional radiology
Contraindications procedures are
• Same risk as of any puncture such as hemor-
• noncooperative patient, rhage and infection.
• inaccessible to puncture, • Secondary echinococcosis caused by spillage.
• cyst communicating with biliary tree, • Anaphylactic shock or allergic reaction.
• inactive/calcified cyst. • Chemical cholangitis if cyst communicates
with biliary tree.
–– PAIR-D (D=Drainage) is a variant of PAIR • Systemic toxicity of scolicidal agent if cyst is
associated with insertion of intracystic large.
Advantages of Interventional radiology proce- Surgical procedures can be conservative pro-

dures are cedures (partial cystectomy or deroofing, marsu-
• Minimal invasiveness. pialization, and external drainage) or radical
• Require less expertise. procedures (pericystectomy, subadvential cystec-
• Reduced risk compared to surgery. tomy, and formal liver resection). These proce-
• Reduced hospital time. dures can be performed laparoscopically or via
• Cost effective. open surgery. There are a few contraindications
• Can be performed in remote areas with less of laparoscopic procedure and these are
infrastructures
• Surgery. • Severe cardiopulmonary disease is unlikely to
tolerate prolonged CO2-induced pneumoperi-
toneum and deemed unfit for laparoscopy by
Preoperative evaluation includes the anesthesiologists.
• Complete blood count and blood grouping. • Previous multiple upper abdominal surgery
• Electrocardiogram. likely to have adhesions and thus limiting
• Electrolytes. vision and increasing the difficulty level of
• PT/INR. laparoscopic dissection.
• Renal and Liver function test. • Recurrent hydatid cysts.
• Review of imaging—triphasic CT or MRI • Deep located cysts.
• Rupture of cyst in biliary tree.
Indications of surgery are Conservative procedures are safe and techni-

• Complicated cysts. cally simple. However, their disadvantages are
• Large CE2-CE3b cysts. high postoperative complications and recurrence
• Single liver cyst located superficial and carries rate as shown in Table 2. Radical procedures have
risk of perforation (such as following trauma). a lower rate of recurrence [21] but many authors
• Cyst communicating biliary tree. still consider them inappropriate, claiming that
• Infected cyst. intraoperative risks are too high for benign dis-
• Cyst exerting pressure effects on adjacent ease [22].
vital organ
Table. 2 Complications of conservative surgery

Contraindication for surgery are Early Late
• General contraindication such as multiple • Liver-related complications • Biliary
– Bile leakage fistula
medical comorbidities. – Residual cavity • Biliary
• Multiple cysts in multiple organs. infection/abscess stricture
• Cysts that are difficult to access. – Perihepatic collection/ • Recurrence
• Dead calcified cyst. hematoma
– Hepatic abscess
• Very small cyst • Spillage-related
complications
– Secondary hydatosis
Aims of surgery are – Anaphylaxis
• Scolicidal-induced
• Complete extirpation of the parasites. complication
• Obliteration of residual cavity. – Chemical sclerosing
• Identification and management of biliary fis- cholangitis
tula and other complications – Methemoglobinemia
326 R. K. Gupta
Endoscopic management: ERCP will be help- patient but may stand between the legs of the
ful for major biliary communication with dilated patient placed in a “Y” position.
bile duct [23].
Technique
• All patients are operated under General anes-
perative Details of Various
O thesia with a Foley’s catheter and nasogastric
Surgical Procedures tube placed immediately after induction in
either supine position or the French position
Laparoscopic Deroofing, a conservative proce- • A 10 mm port at the umbilicus houses the 30°
dure Iis most common surgery being performed telescope. A 5 mm trocar is placed just below
for hydatid cyst. the xiphoid process to the right or the left of
the falciform ligament, depending on the
Recommended instruments location of the cyst. This port is used to
• One 10 mm trocar. expose the liver. One 5 mm and one 10 mm
–– A 30° angled laparoscope. ports, in the right and left flank, allow the
–– Two 5 mm trocar. surgeon to puncture the cyst dome, aspirated
–– One 10 mm trocar. its contents, and excise the cyst wall in a
–– One 5 mm grasping forceps. careful sequential fashion to facilitate
–– One generated grasping forceps. homeostasis (Fig. 2.
–– A 5 mm hook. • A gauge soaked with 3% saline or 10% beta-
–– Irrigation and aspiration probe. dine is kept around the cyst to prevent con-
–– Energy devise: (Harmonic scalpel, ligasure, etc.). tamination by spillage before puncture of the
–– Specimen retrieval bag. cyst (Fig. 3).
–– Liver detractors (may be required to retract liver) • Decompression of the cyst by aspiration of the
cyst fluid using a wide bore needle through
Figure1 describes operation theater setup and one of the 5-mm ports or by direct percutane-
position of surgeon and the assistants. The sur- ous entry under laparoscopic guidance taking
geon usually stands on the left-hand side of the care to avoid spillage and by the use of at least
Surgeon
Assistant
Camera man
Fig. 1 Operation theater setup and position of surgeon

and the assistants Fig. 2 Port placement
Fig. 3 Cystic lesion isolated from rest of abdominal cavity with Betadine-soaked gauge
one continuous suction cannula around the

Daughter cyst
needle puncture site.
• Once cyst is punctured, cyst content should be
examined as further step depends on it. In a
typical viable cyst, the content will be clear
with sand and debris of broad capsules. The
content will be initially clear and later turns
bilious in case of cyst with biliary communi-
cation due to valvular mechanism. (Biliary
system pressure is 15–20 cm of H2O while
intracystic pressure is 30–80 cm of H2O)
Infected cyst has purulent content with flakes.
Dead cyst has toothpaste-like content.
• Aspiration of as much of the cyst fluid and
injection of equal amounts of scolicidal agents
(10% povidone iodine or hypertonic saline)
into the cyst cavity without removing the nee-
dle. Hypersonic saline is preferred because
stain of providing iodine may mimick bile
leak. In case of biliary communication, avoid
injection of scolicidal agent 10% betadine
Fig. 4 Aspiration of cyst content with 10 mm suction
because of fear of chemical cholangitis.
• Aspiration of the cyst contents after 10 min
using high-powered suction at a negative pres- • Once the dome of cyst is deroofed, all residual
sure via 10 mm trocar introduced directly into elements should be evacuated until the cavity
the cyst under vision (Fig. 4). is clear.
• Scoring of Glisson‘s capsule of area to be • Direct inspection of the interior of the cyst by
deroofed with high-frequency electrosurgery. introducing the scope into the cyst to look for
• Mesenchymal dissection can be performed remaining cyst elements and biliary leakage,
using ultrasonic dissector. if any, for subsequent attention.
328 R. K. Gupta
• Removal of the cyst wall and cyst elements by –– Omentoplasty: It is the option of choice
using an impermeable specimen bag. nowadays. A viable flap of omentum is
• The specimen is extracted either by partial sutured to cyst cavity and drain is kept.
morcellation, dilatation at the umbilicus, • Sending scolices for confirmation by micros-
enlarging another port site or by a small MC copy or for culture, if deemed infected.
Burney or subcostal incision.
• Cholangiography or ICG (Fig. 5) is useful to
detect bile leak. Other Operative Procedures
• Inspection of raw surface of liver, and if
required it is covered with fibrin glue. Radical procedures include pericystectomy, sub-
• Management of Residual cavity: Various advential cystectomy, and formal liver resection
options are (Fig. 6). Radical surgery has pros and cons shown
–– Water-tight suturing without drain. in Table 3.
–– Marsupialization. Indications of radical procedure are:
–– Capsulorrhaphy and Capitonnage.
–– Large cystobiliary communication—unable to
manage by Roux-en-Y anastomosis.
–– Hydatid cyst with biliary obstruction leading
to atrophy of segment.
Complications of Hydatid cysts of liver: The

most common complications in order of fre-
quency are infection, biliary communication,
rupture into peritoneal cavity/pleural cavity, and
portal hypertension [24].
Fig. 5 Indocyanine Green (ICG) imaging showing no
biliary communication of cyst
Fig. 6 (a) various layers

a Hepatic tissue
of hydatid cyst
Adventitial layer
(b) total cystectomy
Laminated layer Echinococcal
(c) subtotal cystectomy cyst
(d) hepatectomy Germinal layer
b
Total cystectomy
c Sub-total
cystectomy
d
Hepatectomy
Table 3 Pros and cons of radicle procedure 3. Lantinga MA, Gevers TJ, Drenth JP. Evaluation
of hepatic cystic lesions. World J Gastroenterol.
Pros Cons
2013;2119(23):3543–54.
Complete eradication of Expertise required 4. Li X, Zhang JL,WangYH, et al. Hepatobiliarycystadenoma
cyst Time-consuming and acstadenocarcinoma: a single center experience.
Less recurrence More morbidity Tumori. 2013;99(2):261–5.
Less biliary complication Too radical for cystic 5. Giorgio A, Esposito V, Farella N, et al. Amoebic liver
No residual cavity hydatid abscesses: a new epidemiological trend in a non-
endemic area. In Vivo. 2009;23(6):1027–30.
6. Bosanko N, et al. Presentations of pyogenic liver
iliary Communication and its
B abscess in one UK centre over a 15 year period. JR
Coll Physicians Edinb. 2011;41:13–7.
Management 7. Nazir NT, Penfield JD, Hajjar V. Pyogenic liver
abscess. Cleve Clin J Med. 2010;77(7):426–7.
The incidence of cysto-biliary communication 8. Jha AK, Das G, Maitra S, et al. Management of large
ranges between 3 and17% [25]. The rupture of amoebic liver abscess- a comparative study of needle
aspiration and catheter drainage. J Indian Med Assoc.
hydatid cysts into biliary ducts and the migration 2012;110(1):13–5.
of the hydatid material in the biliary tree lead to 9. Singh V, Bhalla A, Sharma N, et al. Pathophysiology
other biliary complications such as cholangitis, of jaundice in amoebic liver abscess. Am J Trop
sclerosis odditis, and hydatid biliary lithiasis. The MedHyg. 2008;8(4):556–9.
10. Abbas MT, Khan FY, Muhsin SA, et al. Epidemiology,
diagnosis of this complication can usually be made clinical feature and outcome of liver abscess: a single
by using ultrasound and abdominal CT scan. The reference center experience in Qatar. Oman Med J.
presence of dilated common bile duct, jaundice, 2014;29(4):260–3.
close proximity of cystic lesion to major ducts are 11. Cai YL, Xiong XZ, Lu J, et al. Percutaneous needle
aspiration versus catheter drainage in the management
strongly suggestive of cystobiliary communica- of liver abscess: a systemic review and meta-analysis.
tion. The various treatment options are as follows: HPB(Oxford). 2015;17(3):195–201.
12. Levin DC, Eschelman D, Parker L, Rao VM. Trends
• Direct suturing of fistula orifice with the in use of percutaneous versus open surgical grainage
of abdominal abscesses. J Am CollRadiol. 2015;12(12
absorbable suture is indicated if perifistulous PtA):1247–50.
cyst wall is not calcified or too fibrotic. If 13. Zhang W, Ross AG, McManus DP. Mechanisms of
calcified, suturing with omentoplasty may be immunity in hydatid disease: implication for vaccine
helpful. development. L Immunol. 2008;15181(10):6679–85.
14. Wenbao Z, Li J, McManus DP. Concepts in immunol-
• In case of hydatid cyst in main biliary tree, ogy and diagnosis of hydatid disease. Clin Microbiol
CBD exploration with removal of cyst mate- Rev. 2003;16(1):18–36.
rial with T-tube drainage is indicated if ERCP 15. Moro P, Schantz PM. Echinococcosis: a review.
is not available. International Journal of Infectious Disease.
2009;13:125–33.
• Cyst communication with a large duct may 16. Fadel SA, Asmar K, Faraj W, Khalife M, Haddad M,
require drainage with Roux-en-Y El-Merhi F. Clinical review of liver hydatid disease
hepaticojejunostomy. and its unusual presentations in developing countries.
• Radical surgery is the best procedure for large AbdomRadiol (NY). 2019;44(4):1331–9.
17. Magistrelli P, Massetti R, Coppola R, Messia
biliary-cyst fistula. A. Surgical treatment of hydatid disease of liver: a 20
year experience. Arch Surg. 1991;126:518–23.
18. PAIR: Puncture, Aspiration, Injection, Re-aspiration-
References An option for the treatment of Cystic Echinococcosis.
WHO/CDS/CSR/APH/2001.6.
19. Giorgio A, Tarantino L, Francica G, et al.
1. Gloor B, Ly Q, Candinas D. Role of laparoscopy in
Unilocularhydatid liver cysts: treatment with
hepatic cyst surgery. Dig Surg. 2002;19:494–9.
US-guided, double percutaneous aspiration and alco-
2. Gamblin TC, Holloway SE, Heckman JT,
hol injection. Radiology. 1992;184(3):705–10.
GellerDA. Laparoscopic resection of benign
20. Schipper HG, Lameris JS, van Delden OM, Rauws EA,
hepatic cysts: a new standard. J Am Coll Surg.
Kager PA. Percutaneous evacuation of multivesicular
2008;207:731–6.
330 R. K. Gupta
echinococcal cysts with or without cystobiliary fistula 23. Ersan O, Yusuf B. Endoscopic therapy in the
which contain non-drainable material: first results of a management of hepatobiliaryhydatid disease. J
modified PAIR method. Gut. 2002;50(5):718–23. ClinGatroenterol. 2002;35:16–174.
21. Deo KB, et al. Surgical management of hepatic 24. Khanfar N. Hydatid disease: a review and update.
hydatid cyst- conservative versus radical surgery. Current Anaesthesia& Critical Care. 2004;15:173–83.
HPB.2020.03.003. 25. Eckert J, Deplazes P. Biological, epidemiologi-
22. Balik A, et al. Surgical treatment of hydatid dis- cal, and clinical aspects of echinococcosis, a zoo-
ease of liver review of 304 cases. Arch Surg. nosis of increasing Cancer. ClinMicrobiol Rev.
1999;134:166–9. 2004;17(1):107–35.
Laparoscopic Wedge Liver
Resection
Introduction Indications for Laparoscopic Wedge

Liver Resection [1, 3]
Laparoscopic liver resection was introduced as a
surgical technique more than two decades ago. 1. Superficial lesion of 5 cm or less in diameter.
The initial successful laparoscopic anatomical 2. Small peripherally located lesions [left-lateral
hepatectomy was reported in 1996 by Azagra segments, segment VI, or the anterior segment
et al., who performed a left-lateral segmentec- of the right liver (segment V)].
tomy in a patient with a benign adenoma of seg- 3. Lesions of 3 cm or less in diameter in other
ments II and III [1, 2]. The technique has grown segments.
from a novel procedure to an essential compo-
nent of the highly specialised hepatobiliary unit Peripherally located lesions are desirable for
armamentarium. Amongst the advantages of lap- laparoscopic resection as they are often devoid of
aroscopic liver surgery are: reduced hospital stay, large venous structures, require less mobilisation
reduced postoperative pain, lowered risk of peri- and dissection, and easily controlled should
toneal adhesions, better cosmetic outcomes, and bleeding occur [4]. Nonetheless, sound oncologic
much shorter convalescence [3]. principles as in open surgery must be observed
Laparoscopic wedge liver resection is often during laparoscopic wedge resection for malig-
selected as the starting point for most hepatobili- nancy which are radical resection, and at least
ary surgeons during their laparoscopic liver sur- 1 cm free surgical margin. Owing to the lack of
gery endeavour. It is commonly a nonanatomical digital palpation during laparoscopic wedge
resection performed for benign or malignant resection, routine use of intraoperative ultraso-
indication [1]. nography to precisely locate the tumour and to
plan the division of liver parenchyma has become
mandatory [4].
Contraindications
A. R. Yusoff (*)
Department of Surgery, Universiti Teknologi MARA,
Sg. Buloh, Selangor, Malaysia These are mainly related to the anatomy, size,
D. Lomanto and location of the lesions. (Some could be of
Department of Surgery, YLL School of Medicine, relative contraindication in a good, high-volume
National University Singapore, center) [1, 4].
Kent Ridge, Singapore

https://doi.org/10.1007/978-981-19-3755-2_47
• A large tumour (>5 cm in diameter). Access and Port Position

• Lesions at the superior aspect of the liver, i.e.,
segments VII and VIII. • Place a 10 mm supraumbilical port for the
• Lesions near the major hepatic veins, inferior telescope.
vena cava, and hepatic hilum. • Place two 12 mm working ports in both right
• Evidence of severe portal hypertension. and left flanks. The 12 mm right flank port
• Presence of coagulopathy and may be replaced with Gelport→ for hand-
thrombocytopenia. assisted surgery.
• Insert another 5 mm assistant port in the epi-
gastrium or the right or left subcostal along
Preoperative Assessment the mid-clavicular line depending on the site
of the lesion.
Please refer to the previous text in the manual.
Scope and Pneumoperitoneum
OT Setup • Use a 30° and 10mm laparoscope.

• Set CO2 pressure at 12 mmHg with medium
Instrumentations flow at 10 L/min.
• Laparoscopic trocars and cannula (2 × 12 mm,

1 × 10 mm, 2 × 5 mm). Exploration
• Hand-assisted port GelPort→ (optional).
• 10 mm 30°telescope Assess the liver by intraoperative laparoscopic
• Laparoscopic intraoperative ultrasound. ultrasound to determine the size and location of the
• Energy devices (Harmonic, Ligasure, lesion, to identify additional lesions, and to deter-
Monopolar diathermy). mine the feasibility of laparoscopic resection.
• Cotton tape, silicone snugger (For Pringle’s
manoeuvre—optional).
• Topical haemostatic agent Mobilization
(Surgicel→—optional).
• Endoscopic vascular stapler (optional). • Divide the attaching ligaments of the liver (the
• Endoscopic retrieval bag. round, falciform, and triangular ligaments)
(Fig. 1).
• Divide both the right and left triangular, and
Patient’s Position coronary ligaments according to the site of the
lesion.
• Supine position with both lower limbs in the
abduction.
• The surgeon stands in between the patient’s legs.
• Left-lateral position may be used for limited
resection of segment VI.
Technique
(shown here is the technique for laparoscopic

hand-assisted nonanatomical liver resection of
segment VI tumour) Fig. 1 Division of falciform ligament for liver mobilization
Laparoscopic Wedge Liver Resection 333
• Prepare Pringle’s manoeuvre, although this is • For suitable cases, divide any pedunculated
not routine for wedge resection; it is good to lesions with an endoscopic linear stapler.
prepare for one in case of bleeding. Place tape • Pack or apply the topical haemostatic agent to
around the porta hepatis and pass it into a sili- the parenchymal defect or use bipolar cautery
cone drain and secure it on the outside of the or clips to secure haemostasis (Figs. 5 and 6).
abdomen through an assistant port.
Parenchymal Transection
• Mark the surface of the liver parenchyma for

transection by electrocautery, taking into
account the 1 cm margin for a malignant
lesion.
• Use hook electrocautery for parenchymal
transection (Fig. 2).
• Alternatively, the harmonic scalpel (Ethicon,
US) can be used for more convenient resec- Fig. 4 Deeper parenchymal dissection with Harmonic
tion and simultaneous haemostasis (Figs. 3 scalpel
and 4).
Fig. 5 Appearance of the cavity in segment VI of liver

Fig. 2 Marking the area for tumour dissection with 1 cm after nonanatomical resection of the tumour
margin using hook diathermy
Fig. 6 The cavity left after the resection is packed with

Fig. 3 Initial tumour dissection with Harmonic scalpel haemostatic agent
Extraction Late
• Biloma.
• For small specimen, use an endopouch to • Subphrenic abscess.
retrieve it from either one of the 12 mm flank • Incisional hernia.
ports.
• For larger specimen, replace the 12 mm port
with a 15 mm trocar for insertion of a larger Postoperative Management
endopouch. Place the specimen in the bag and
extract it out with the 15 mm trocar. • Early feeding.
• Stop the CO2 insufflation, and incise the skin • Adequate analgesia.
and fascia at the 15 mm trocar site to retrieve • Early ambulation.
the bag and the specimen. • Placement of a subhepatic drain (optional).
• Close the fascia carefully with an absorbable • Deep venous thrombosis prophylaxis.
suture.
Complication of Laparoscopic References

Wedge Liver Resection
1. Clavien P-A, Sarr MG, Fong Y, Miyazaki M. Atlas of
upper gastrointestinal and hepato-pancreato-biliary
Although uncommon as this is considered minor surgery. Springer; 2015.
hepatic resection, potential complications include; 2. Cannon RM, Brock GN, Marvin MR, Buell
JF. Laparoscopic liver resection: an examination of our
Early first 300 patients. J Am Coll Surg. 2011;213(4):501–7.
3. Sasaki A, Nitta H, Otsuka K, Takahara T, Nishizuka S,
• Intra-abdominal haemorrhage especially in Wakabayashi G. Ten-year experience of totally laparo-
cirrhotic liver. scopic liver resection in a single institution. Br J Surg.
• Bile leak. 2009;96(3):274–9.
• Bowel ileus. 4. Gigot J-F, Glineur D, Azagra JS, Goergen M, Ceuterick
M, Morino M, et al. Laparoscopic liver resection for
• Wound infection. malignant liver tumours: preliminary results of a mul-
ticenter European study. Ann Surg. 2002;236(1):90.
Laparoscopic Left Liver Resection
Introduction Patient Selection
Liver resection is basically parenchymal transec- LLH is indicated for:

tion and vessels, bile ducts control which is
related to risk of major bleeding, bile leak, and 1. Benign or malignant lesions are located in the
unwanted injury of hepatic remnant. Distribution left liver (segments 2, 3, 4) while less resec-
of vessels and bile ducts consists of two parts. tion is inappropriate.
One is hepatic veins. The other is hepatic pedi- 2. Donor of the living liver transplantation.
cles which are covered by Glisson’s capsule and
located deeply in the hepatic parenchyma. This
leads to technical difficulties as controlling Procedure
inflow and outflow. This is explanation for limita-
tion of applying laparoscopic surgery in major Generally, there are many types of laparoscopic
anatomical hepatectomy such as right hepatec- approach in left liver resection. They are dorsal
tomy and left hepatectomy. approach, Arantius-first approach, glissonean
In recent years, laparoscopic left hepatectomy pedicle approach, and anterior approach [1–3]. In
(LLH) becomes more common all over the world. this chapter, we describe technically LLH with
Its indication includes both benign and malignant combination of glissonean pedicle approach and
liver lesions. Most of laparoscopic left hepatec- anterior approach [3, 4].
tomy are done in specialized centers with HBP
experts. However, it is reported that this proce-
dure is feasible and safe. perating Room Setup, Patient
O
Positioning, and Surgical Team
P. M. Hai
Department of Hepatobiliary and Pancreatic Surgery, Patient is placed in supine reverse Trendelenburg
University Medical Center, Ho Chi Minh city,
position. The arms should be tucked at the
Vietnam
patient’s sides. The legs are abducted.
L. Q. A. Tuan (*)
Operating room setup is described in (Fig. 1)
Department of Hepatobiliary and Pancreatic Surgery,
University Medical Center, Minimally Invasive
Surgical Training Center, Ho Chi Minh City, Vietnam
Department of General Surgery, University of
Medicine and Pharmacy, Ho Chi Minh City, Vietnam

https://doi.org/10.1007/978-981-19-3755-2_48
336 P. M. Hai and L. Q. A. Tuan
Technique 2. Exploration
Staging is very important in case of malig-
1. Trocar placement nant or suspected malignant lesions. Abdominal
First 12 mm trocar is placed at the inspection is performed to assess the liver, peri-
umbilicus. toneal, and mesenteric metastases.
Another 12 mm trocar and three 5 mm tro- Intraoperative ultrasonography is very use-
cars are placed as in (Fig. 2) ful to determine the size, location, number of
the lesion, satellite nodules, and the level of
liver cirrhosis. This helps to decide the resect-
ability or an alternative surgical plan.
Indocyanine green (ICG) can also be used for
the purpose of exploration.
3. Mobilization of the left liver
Nurse
Mobilization of left liver is performed by
dividing round ligament, falciform ligament,
left coronary ligament and part of right coro-
nary ligament, left triangular ligament, and
Assistant then hepatogastric ligament. A cholecystec-
Surgeon
tomy is always done in our technique.
4. Hepatic hilum dissection
We perform Glissonean pedicle dissection
according to Takasaki’s technique. As a result,
Camera man
left hepatic pedicle is encircled with a tape.
Then, left hepatic pedicle is temporarily
clamped with bulldog clamps to confirm the
efficacy of pedicle clamping and to visualize
Fig. 1 OR setup
the ischemic demarcation line as well (Fig. 3)
Fig. 2 Trocar position

Laparoscopic Left Liver Resection 337
Middle hepatic vein
Fig. 5 Middle hepatic vein as anatomical landmark
Fig. 3 Clamping of left hepatic pedicle 6. Transection of the left hepatic pedicle and
left hepatic vein
The bulldog clamps are removed and the
left hepatic pedicle is divided by a vascular
stapler. Other alternatives are using large
clips, ligation, or suturing before transection.
Care should be taken to avoid stenosis of the
right hepatic duct (Fig. 5).
Although the left hepatic pedicle can be
divided before parenchymal dissection, we pre-
fer it after parenchymal dissection because of
Fig. 4 Parenchymal dissection better visualization of the left hepatic pedicle
and better free space around it that may lower
5. Parenchymal dissection the risk of bleeding and lower the risk of inad-
According to the demarcation line on dia- vertent injuries in case of anatomical variation.
phragmatic surface and visceral surface of the Then comes the separation of the left liver
liver, the parenchyma is dissected using ultra- from caudate area.
sonic shears or CUSA (Fig. 4). After that, left hepatic vein is exposed and
In superficial 2 or 3 cm of liver paren- divided. Vascular staplers, ligation, or sutur-
chyma, there are no major vessels. Hence, we ing can be used. Care should be taken to avoid
can dissect liver parenchyma safely with injury to the middle hepatic vein.
energy devices. When proceeding to deeper 7. Hemostasis
parenchyma, vascular structures should be Bleeding and bile leakage is carefully
recognized using crush-clamp technique and inspected. Clips or sutures are used for bleed-
clipped before dividing. The parenchymal dis- ing and bile leak.
section should be peripheral to central direc- 8. Removal of specimen
tion with the left side of the middle hepatic Specimen is placed in a retrieval bag. A
vein as the landmark. (Fig. 5). drain is usually placed close to the raw surface
Hepatic parenchymal dissection is contin- of the liver. The specimen is extracted through
ued to caudate area. The left hepatic pedicle is expanded incision of umbilical port or
then well exposed. Pfannenstiel incision.
Complications References
The main complication of laparoscopic left hepa- 1. Okuda Y, Honda G, Kurata M, Kobayashi S, Sakamoto K.
Dorsal approach to the middle hepatic vein in lapa-
tectomy is bleeding. It is better to prevent bleed- roscopic left hemihepatectomy. J Am Coll Surg.
ing than to stop bleeding. When bleeding occurs, 2014;219(2):e1–4.
we have many options including bipolar coagula- 2. Ome Y, Honda G, Kawamoto Y. Laparoscopic
tion, vessel sealing devices, clips, staplers, and left Hemihepatectomy by the Arantius-first
approach: a video case report. J gastrointest Surg.
sutures. Laparoscopic suturing skill is important 2020;24(9):2180–2.
in laparoscopic liver resection. When there is no 3. Takasaki K. Glissonean pedicle transection method for
progress in a certain period or uncontrollable hepatic resection: a new concept of liver segmentation.
bleeding, conversion should be considered. J Hepato-Biliary-Pancreat Surg. 1998;5(3):286–91.
4. Jamieson GG, Launois B, Cherqui D, Randone B,
Gayet B, Machado MAC. Hepatectomies by laparo-
scopic approach: intra-Glissonian approach versus
Summary extra-Glissonian and posterior approach. In: Launois
B, Jamieson GG, editors. The posterior intrahepatic
approach in liver surgery. New York, NY: Springer
Laparoscopic left hepatectomy is more common New York; 2013. p. 143–69.
but technically demanding. Parenchymal dissec-
tion should be peripheral to central with middle
hepatic vein as the landmark. Bleeding is the
most important issue in laparoscopic liver
resection.
Laparoscopic Right Hepatectomy
Brian K. P. Goh
Introduction Access and Port Position
Laparoscopic liver resection was first performed 1. Usually 5–6 ports are used (another 5 mm
over two decades ago and is widely adopted in many port may be used for application of the extra-
institutions worldwide today [1]. However, laparo- corporeal Pringles maneuver.
scopic liver resection especially for major hepatec- 2. Place an initial 12 mm port for the camera at
tomies remains a highly complicated and technically the right hypochondrium (4–5 cm from the
demanding procedure and is routinely performed midline).
only by specialized surgeons in high-volume cen- 3. Place two 12 mm working ports to the right
ters today [2, 3]. In this chapter, we share the opera- and left of the initial port (about 5 cm from the
tive techniques adopted at our institution based on camera port.
our experience with over 800 laparoscopic liver 4. Insert another two 5 mm assistant ports at
resections performed to date [1, 2, 4, 5]. right subcostal and epigastrium.
5. Place another 5 mm port in the left hypochon-
drium if the extracorporeal Pringles Maneuver
Surgical Technique is used.
Position
Scope and Pneumoperitoneum
1. Reverse Trendelenburg position.
2. Supine position with primary operator on the 1. A rigid 30°–10 mm laparoscope or a flexible
right side. tip 0°–10 mm laparoscope.
3. Alternative position: Supine with both limbs 2. Set CO2 pressure at 12 mmHg with high flow.
abducted and surgeon stands between the legs. 3. Two gas insufflators or the AirSeal device
may be used to maintain a constant
B. K. P. Goh (*) pneumoperitoneum.
Department of Hepatopancreatobiliary and Transplant
Surgery, Singapore General Hospital and National
Cancer Centre Singapore, Singapore Liver Transplant
Service, SingHealth Duke-National University of Exploration
Singapore Transplant Centre, Singapore, Singapore
SingHealth Duke-NUS Liver Transplant Center, 1. Use of intraoperative laparoscopic ultrasound
Duke-National University of Singapore Medical is imperative to determine the size and
School, Singapore, Singapore

https://doi.org/10.1007/978-981-19-3755-2_49
340 B. K. P. Goh
location of the lesions and to identify addi- Inflow Control

tional lesions.
2. To identify key anatomical structures/land- 1. After cholecystectomy, proceed to dissect
marks such as the right hepatic vein, middle and identify the inflow structures (after
hepatic vein (MHV) (which is critical in guid- dividing the cystic artery and duct, the gall-
ing parenchyma transection), and the right bladder can be left attached to the liver to aid
Glissonian pedicle (including right anterior in retraction during hilar dissection).
and right posterior pedicles. 2. Inflow control can be obtained via several
approaches:
(a) The classical extrahepatic intrafascial
Mobilization approach.
(b) Extrahepatic Glissonian Approach.
1. Use monopolar energy to divide the ligaments (c) Intrahepatic Glissonian Approach.
of the liver (the round, falciform, and triangu- 3. Extrahepatic dissection:
lar ligaments). (a) This approach is essential for living
2. Divide both the right and left triangular, and donor hepatectomy and tumors located
coronary ligaments according to the site of the close to the hilum.
lesion. (b) Right hepatic artery is usually identified
3. Rotating the table clockwise will allow grav- posterior to right hepatic duct and ante-
ity to assist in liver mobilization. rior to the right portal vein.
4. Mobilize the liver off the inferior vena cava (c) Right portal vein is dissected from the
(IVC) taking the short hepatic veins in a cau- Glissonian sheath identifying the bifur-
dal to cranial direction (be aware of possible cation with the left portal vein. Division
large inferior right hepatic veins which can be of the caudate branch is useful to obtain
identified on preoperative imaging) (the IVC additional length on the right portal vein.
should be flat implying a low central venous The portal vein is encircled with a tie.
pressure). (d) Test clamping of the right portal vein
5. Division of the IVC ligament is critical to and right hepatic artery should be per-
enable division of the right hepatic vein later. formed to identify the ischemic line
6. It may not always be possible to mobilize the prior to ligating these structures.
liver completely off the cava especially crani- (e) Indocyanine green by negative staining
ally in all patients (especially with liver hav- may be used to aid in the identification
ing a long craniocaudal diameter). This can be of the ischemic line, especially in cases
done later after transection of the liver with chemo-damaged liver or cirrhosis.
parenchyma. (f) At least two clips should be placed to the
7. This step of mobilization of the liver can also staying side of the right hepatic artery
be performed after parenchymal transection and portal vein to reduce the risk of slip-
instead of being performed as the initial step page and postoperative bleeding.
as in the medial to lateral approach. This is (g) The right hepatic duct is divided only
especially useful for patients with a large right after wide parenchyma transection to
lobe or in the presence of a bulky tumor. reduce the risk of common hepatic duct
8. Prepare Pringle’s maneuver: encircle the porta stricture.
hepatis with tape and pass it outside the abdo- 4. In the extrahepatic Glissonian approach to
men through a 5 mm port. the right pedicle, identification of the blood-
Laparoscopic Right Hepatectomy 341
less space between Laennec’s capsule and 2. Small (<5 mm) biliovascular structures can
the Glissonian sheath as described by be divided with the energy device.
Suigioka et al. [6] is essential. 3. Larger structures are clipped with metal clips
5. In the intrahepatic Glissonian approach, the or self-locking clips.
hepatic parenchyma is transected anteriorly 4. Reducing the number of clips applied unnec-
and posteriorly to the right pedicle or alterna- essarily is important to minimize clip
tively small hepatectomies as described by slippage.
Machado et al. [7] can be created. 5. It is useful to perform transection of the para-
6. Both extrahepatic and intrahepatic Glissonian caval portion of the caudate early to allow
approaches are generally quicker to perform control of the right hilar structures.
compared to the classical extrahepatic inter- 6. Transection of the hepatic parenchyma pro-
facial approach. ceeds in a caudo-cranial direction along the
7. An important point to note is that a complete MHV and the two lobes of the liver are
360° dissection of the Glissonian pedicle is gradually separated like an open book.
not essential and may result in troublesome Segment V tributaries are easily identified
bleeding as the terminal branches for the and divided.
MHV are in close proximity. Usually, dissec- 7. Once the parenchyma has been widely tran-
tion of about 180°–270° of the right sected, the right Glissonian pedicle can be
Glissonian pedicle is adequate to allow divided with clips or vascular stapler (if this
application of the laparoscopic bull-dog has not been done previously as with the
clamps and identification of the ischemic extrahepatic or intrahepatic Glissonian
line. approach).
8. Division of the Glissonian pedicle can be 8. Parenchyma transection continues cranially
performed safely with vascular staplers after along the MHV and careful identification of
the liver parenchyma has been transected segment VIII hepatic vein branches espe-
widely including transection of segment IX. cially of segment VIII ventral is critical to
9. It must be ensured that the stapler is applied avoid shearing of these venous tributaries
away from the hepatic duct bifurcation to from the MHV resulting in troublesome
avoid common hepatic duct stricture. bleeding.
10. When feasible especially in the presence of a 9. Finally, the root of the right vein is isolated
short right Glissonian pedicle, separate divi- and this is stapled off with the vascular
sion of the right anterior and posterior pedi- (white reload).
cles will avoid accidental narrowing of the 10. Vascular clamps should always be ready at
common hepatic duct. this final step as a misfire of the stapler can
result in catastrophic bleeding.
11. After completion of transection, the liver sur-
Parenchyma Transection face should be inspected for bile leak and
bleeding. This should be performed with a
1. This is usually performed with a Cavitron Valsalva maneuver after rehydration of the
Ultrasonic Surgical Aspirator in combination patient and with the pneumoperitoneum low-
with an energy device such as harmonic scal- ered to about 5 mmHg.
pel (Ethicon, USA) or Thunderbeat 12. Hemostatic adjuncts may be used on the
(Olympus, Japan). A bipolar forceps is also transected liver parenchyma surface.
essential. Use intraoperative ultrasound 13. A closed suction drain is placed in selected
intermittently to guide the transection plane. cases.
342 B. K. P. Goh
Extraction ence with its first 120 consecutive cases. ANZ J Surg.
2020;20:553–7.
3. Chua D, Syn N, Koh YX, Goh BK. Learning curves
1. The specimen is placed in a large bag and in minimally invasive hepatectomy: systematic
extracted via a lower midline or Pfannenstiel review and meta-regression analysis. Br J Surg.
incision. 2021;108:351–8.
4. Goh BK, Prieto M, Syn N, Koh YX, Lim KI. Critical
2. Usually, a 6–8 cm incision is required for appraisal of the learning curve of minimally inva-
extraction. sive hepatectomy: experience with the first 200 cases
of a southeast Asian early adopter. ANZ J Surg.
2020;90(6):1092–8.
5. Kabir T, Goh BK. Contemporary techniques com-
monly adopted for performing laparoscopic liver
References resection. Laparosc Surg. 2018;2:61.
6. Sugioka A, Kato Y, Tanahashi Y. Systematic extrahe-
1. Goh BK, Lee SY, Teo JY, Kam JH, Jeyaraj PR, patic Glissonian pedicle isolation for anatomical liver
Cheow PC, et al. Changing trends and outcomes resection based on Laennec's capsule: proposal of a
associated with the adoption of minimally-invasive novel comprehensive surgical anatomy of the liver. J
hepatectomy: a contemporary single institution expe- Hepatobiliary Pancreat Sci. 2017;24:17–23.
rience with 400 consecutive resections. Surg Endosc. 7. Machado MA, Makdissi FF, Galvao FH, Machado
2018;32:4658–65. MC. Intrahepatic Glissonian approach for lapa-
2. Goh BK, Lee SY, Koh YX, KAm JH, Chan CY. roscopc right segmental liver resections. Am J Surg.
Minimally invasive major hepatectomies: a south- 2008;196:e38–42.
east Asian single institution contemporary experi-
Part XIV
Pancreas
Laparoscopic Internal Drainage
of Pancreatic Pseudocysts
Introduction modified and developed, the latter shows that its

efficacy of PP resolution was similar to that of
According to revised Atlanta criteria, pancreatic surgery and this technique’s complications were
pseudocyst (PP) is a chronic (>4 weeks) fluid col- comparable to surgery. In addition, endoscopic
lection within pancreatic parenchyma or adjacent therapy had benefits of hospitalization, mental
space of pancreas which has no solid debris [1]. health, and cost when compared with surgery
Pancreatic pseudocyst is consequence of acute [6–8]. Currently, surgery still plays an important
pancreatitis in most cases. However, it may be role in the management of PP. Typically, surgical
consequence of chronic pancreatitis, pancreatic treatment includes surgical drainage (internal and
trauma, or pancreatic operation [2]. external) and excision. Both can be done by open
There are variety of clinical manifestations or laparoscopic surgery. This chapter focuses on
from asymptomatic to appearance of complica- technically laparoscopic internal drainage.
tions. Symptoms can be pain, nausea, and vomit-
ing. Sometimes we can see upper gastrointestinal
bleeding. Infection, hemorrhage, and rupture of Patient Selection
cyst are the most common complications of PPs
[3, 4]. Because of the benefits of nonoperative interven-
Surgery has been main treatment method for tion, such as endoscopic internal drainage and
PP for nearly a century from the first surgically percutaneous external drainage, indication of sur-
internal drainage in 1921 [5]. Endoscopic inter- gical internal drainage is limited at present. This
nal drainage emerged from 1975. After being technique is indicated when other drainage pro-
cedures are a failure or cannot perform. Patients
with recurrent pseudocyst are also suitable for
L. Q. A. Tuan (*) this technique and patients with enteric obstruc-
Department of Hepatobiliary and Pancreatic Surgery, tion or biliary obstruction are suitable as well.
Surgical Training Center, Ho Chi Minh City, Vietnam One important thing we need to check care-
fully before doing surgical internal drainage is
Medicine and Pharmacy, Ho Chi Minh City, Vietnam the matureness of PP’s wall. Appropriate time for
e-mail: tuan.lqa@umc.edu.vn this technique is usually after 6 weeks and thick-
P. M. Hai ness is more than 3 mm as well.
University Medical Center,
Ho Chi Minh city, Vietnam

https://doi.org/10.1007/978-981-19-3755-2_50
346 L. Q. A. Tuan and P. M. Hai
Procedure

O
Like other laparoscopic surgery, a flexible table is Nurse

required to change the patient’s position during
the operation. This is necessary because it can
help creating better exposure owing to gravity.
Cautery system should be prepared while energy Assistant
Surgeon
system such as harmonic scalpel or ligasure is
rarely needed. Ideally, there are two monitors
located at the head of the bed over both shoul-
ders’ side. One is for the surgeon and scrub nurse Camera man
and another is for assistants. When lack of facil-
ity, given just one monitor, the placement should
be on the left side of the patient.
Patient’s position is decubitus with slight head Fig. 1 Personnel setup
up. As mentioned, head up help us having better
view resulting from gravity retraction. Patient’s
legs may be split to make space for camera man
or kept close to each other. Arms are usually
tucked to create free spaces for surgeon, assis-
tants, and scrub nurse’s activities. Team is set up
as in Fig. 1.
Technique
Trocar Placement
First trocar is 12 mm in size which is placed at
infra-umbilicus by close technique or Hasson
technique. However, consequence of intra-
abdominal inflammation usually presents, we
prefer to use Hasson technique. One more 12 mm
trocar and two 5 mm trocars are placed as in Fig. 2 Trocar position
Fig. 2.
xposure of Pancreatic Pseudocyst

E difficulties. In this situation, we should change
There are two ways to enter the lesser sac to to the second approach. Second way is trans-
expose PP. One is dividing gastrocolic liga- mesenteric approach. Transverse colic mesen-
ment below gastroepiploic vessels. We have to tery usually adheres to PP’s wall. Hence, one
free enough space for PP’s wall for anastomo- additional advantage of second way is thicker
sis. In this way, we can do either cystogastros- wall which will form a better anastomosis. In
tomy or cystojejunostomy. When inflammation second way, we only open transverse colic
does not present, exposure of PP’s wall is usu- mesentery to enter PP. With respect to trans-
ally performed easily. However, when inflam- mesenteric approach, we only do
mation still exists, this will confront with cystojejunostomy.
Laparoscopic Internal Drainage of Pancreatic Pseudocysts 347
Insight inspection of pancreatic pseudocyst ment. The choice of approach depends on

and cyst wall biopsy. certain case. In case of through transverse
Purpose of insight inspection of PP is explor- mesocolon, opening should be just left of mid-
ing signs of bleeding and pancreatic necrosis dle colic vessels. Sometimes puncturing or
which may lead to postoperative complications. ultrasonography is used before opening cyst.
These complications can cause consequences • Transecting jejunum at level 25–30 cm from
including reoperation or mortality. Because dif- ligament of Treitz by a linear stapler.
ferentiation between PP and other types of pan- • Making a Y anastomosis between Y limb
creatic cysts is a challenge, cyst wall biopsy is (proximal limb) and Rous limb (distal limb).
necessary. Misdiagnosis as PP was reported in up Jejunojejunostomy is performed side to side
to one-third of pancreatic cyst lesions [9]. by a linear stapler too. Distance from anasto-
mosis to stump of distal limb is approximate
Cystogastrostomy or 60–70 cm. we prefer to close enterotomy with
Cystoduodenostomy or continuous suture. Mesenteric defect should
Cystojejunostomy be closed.
Surgical internal drainage includes cystogastros- • Enterotomy is performed close to the end cut
tomy, cystoduodenostomy, and cystojejunostomy of Roux limb. Cystojejunostomy is fashioned
depending on PP’s location. Cystogastrostomy by one more linear stapler and defect of enter-
and cystoduodenostomy are performed when PP’s otomy and cyst are closed by continuous
wall is close to posterior wall of stomach. The for- suture as well.
mer usually happens when PP is located in body or • Placing a drain is usually not necessary.
tail of pancreas. In contrast, the latter usually • Closure of trocar incision.
occurs when PP is located in head of pancreas.
With regard to cystojejunostomy, the procedure
can be done with any position of PP. Among them, Outcomes
pseudocystoduodenostomy seems to be rarely
applied in laparoscopic drainage [10]. Effect of laparoscopic drainage was reached in
Technically, all surgical internal drainages 98% cases and recurrence rate was 2.5% in a sys-
have the same method. That is anastomosing PP’s tematic review [13].
wall with lumen of alimentary tract such as pos- It was also reported associating with low mor-
terior wall of stomach, wall of duodenum, and bidity (<2%) [13]. Postoperative morbidities can
wall of small intestine. For laparoscopic drain- be infection or bleeding. Most of the cases with
age, anastomosis can be done by stapler or sutur- morbidities were conservatively treated.
ing. However, stapler is preferred due to saving
operating time. In cystogastrostomy, there are
some types of techniques such as endogastric, Summary
exogastric, and transgastric approaches [10, 11].
To pseudocystojejunostomy, Roux en Y anasto- Laparoscopic internal drainage is technically fea-
mosis is usually fashioned [12]. Below, we sible. It was associated with high rate of success
describe technically cystojejunostomy with Roux and low morbidity. However, this technique
en Y anastomosis by stapler. should be performed when endoscopic or percu-
After exposing, inspecting, and biopsy PP, taneous drainage is failed or in case of recurrent
below steps will be done one after another: pancreatic pseudocyst because endoscopic or
percutaneous procedure is less invasive than it
• Approaching cyst via incising through trans- and has had benefits of hospitalization and men-
verse mesocolon or through gastrocolic liga- tal health as well.
References 8. Varadarajulu S, Bang JY, Sutton BS, Trevino JM,

Christein JD, Wilcox CM. Equal efficacy of endo-
scopic and surgical cystogastrostomy for pancre-
1. Banks PA, Bollen TL, Dervenis C, Gooszen HG,
atic pseudocyst drainage in a randomized trial.
Johnson CD, Sarr MG, et al. Classification of acute
Gastroenterology. 2013;145(3):583–90.e1.
pancreatitis--2012: revision of the Atlanta classifica-
9. Warshaw AL, Compton CC, Lewandrowski K,
tion and definitions by international consensus. Gut.
Cardenosa G, Mueller PR. Cystic tumors of the pan-
2013;62(1):102–11.
creas. New clinical, radiologic, and pathologic obser-
2. Bradley EL 3rd. A clinically based classifica-
vations in 67 patients. Ann Surg. 1990;212(4):432–43;
tion system for acute pancreatitis. Ann Chir.
discussion 44–5.
1993;47(6):537–41.
10. Zerem E, Hauser G, Loga-Zec S, Kunosić S,
3. Bradley EL, Clements JL Jr, Gonzalez AC. The natural
Jovanović P, Crnkić D. Minimally invasive treatment
history of pancreatic pseudocysts: a unified concept of
of pancreatic pseudocysts. World J Gastroenterol.
management. Am J Surg. 1979;137(1):135–41.
2015;21(22):6850–60.
4. Sankaran S, Walt AJ. The natural and unnatu-
11. Agalianos C, Passas I, Sideris I, Davides D, Dervenis
ral history of pancreatic pseudocysts. Br J Surg.
C. Review of management options for pancreatic pseu-
1975;62(1):37–44.
docysts. Transl Gastroenterol Hepatol. 2018;3(3):18.
5. Parks RW, Tzovaras G, Diamond T, Rowlands
12. Patel AD, Lytle NW, Sarmiento JM. Laparoscopic
BJ. Management of pancreatic pseudocysts. Ann R
roux-en-Y drainage of a pancreatic pseudocyst. Curr
Coll Surg Engl. 2000;82(6):383–7.
Surg Rep. 2013;1(2):131–4.
6. Johnson MD, Walsh RM, Henderson JM, Brown N,
13. Aljarabah M, Ammori BJ. Laparoscopic and endo-
Ponsky J, Dumot J, et al. Surgical versus nonsurgi-
scopic approaches for drainage of pancreatic pseudo-
cal management of pancreatic pseudocysts. J Clin
cysts: a systematic review of published series. Surg
Gastroenterol. 2009;43(6):586–90.
Endosc. 2007;21(11):1936–44.
7. Rogers BH, Cicurel NJ, Seed RW. Transgastric needle
aspiration of pancreatic pseudocyst through an endo-
scope. Gastrointest Endosc. 1975;21(3):133–4.
Laparoscopic Distal
Pancreatectomy
Introduction It is lack of evidence in this condition [4]. This

chapter’s purpose is to describe technically stan-
Distal pancreatectomy (DP) consists of standard dard laparoscopic distal pancreatectomy.
DP (with or without splenic preserving) and
Radical antegrade modular pancreatosplenec-
tomy (RAMPS). The former is also called Procedure
DP. The latter is indicated for malignant or sus-
pected malignant tumors. Both can be performed Generally, standard LDP consists of LDP with
via laparoscopic or open approach. splenectomy and laparoscopic spleen preserving
Laparoscopic distal pancreatectomy (LDP) distal pancreatectomy (LSPDP), also called
was first described and reported in 1996 by Alfred SSLDP (spleen sparing laparoscopic distal
Cuschieri et al. [1]. LDP was initially indicated pancreatectomy)
for chronic pancreatitis. After that, the indication
was expanded to other benign and premalignant
lesions located in body and tail of pancreas. In perating Room Setup, Patient
O
recent years, LDP has not only been developed in Positioning, and Surgical Team
plenty of countries but its indication is also
expanded to body and tail of pancreatic cancers Patient is placed in supine reverse Trendelenburg
[2, 3]. However, application of standard LDP for position. The arms should be tucked at the
pancreatic adenocarcinoma has still been contro- patient’s sides. The legs are abducted.
versial, especially for medium and large tumors. 10 mm laparoscope of 30° or 45° is used.
The main surgeon and scrub nurse are posi-
tioned on the patient’s right side. The first assis-
P. M. Hai tant’s (cameraman) position is between patient’s
Department of Hepatobiliary and Pancreatic Surgery, legs and second assistant stands on the left side.
University Medical Center, The back table is set up on the right side of
Ho Chi Minh city, Vietnam
patient, above the scrub nurse (Fig. 1).
L. Q. A. Tuan (*)

https://doi.org/10.1007/978-981-19-3755-2_51
Inspection
Staging is very important in case of malignant or

suspected malignant lesions. This is a mandatory
step. Abdominal inspection is performed to assess
liver, peritoneal, and mesenteric metastases. Beside
this, we can assess the resectability of tumor.
ancreatic Exposure and Infra-

P
pancreatic Superior Mesenteric Vein
Exposure
After abdomen is carefully explored and signs of

advanced stage are not found, the lesser sac is
entered by dividing gastrocolic ligament below
level of gastroepiploic vessels. Gastrocolic liga-
ment should be divided bilaterally to duodenum
Fig. 1 Personnel setup and splenic flexure of colon to completely expose
body and tail of pancreas. This can cause injuries
to transverse mesocolic vessels, duodenum, and
Surgical Technique transverse colon, especially at the site of pancre-
atic head. Some tips which can help avoiding
In this chapter, we technically describe procedure these consequences are meticulous dissection
of LDP step by step. We describe both LDP with and following landmarks such as gastroepiploic
and without splenectomy. There are six main vessels and duodenum. Greater omentum can
steps during procedure apart from general steps become ischemic after dividing gastrocolic liga-
which are present in most laparoscopic surgeries. ment but there is mostly no need to resect it.
They are [1] exposure of pancreas and infra- Next is mobilization of the stomach. Then
pancreatic superior mesenteric vein, [2] mobiliza- suturing posterior wall of stomach against ante-
tion of transverse mesocolon and splenic flexure rior abdominal wall is done by 2.0 absorbable
of colon, [3] posterior dissection and splenic ves- suture. We prefer to use vicryl. The direction for
sel exposure, [4] upper border of pancreatic neck pulling stomach is cranial and medial. As a result,
and celiac trunk dissection, [5] pancreatic neck superior border of pancreas and celiac trunk may
transection, and [6] separating specimen. LDP be well accessed as we act at below steps.
with splenectomy and LDP without splenectomy Pancreatic lesion is also inspected.
differ from each other at last step. The description Infra-pancreatic superior mesenteric vein
with details will be presented below. (SMV) is dissected at inferior pancreatic border.
Right gastroepiploic and middle colic vein are
important landmarks. SMV is covered by a thin
Trocar Placement layer called adventitial tissue and loose thin con-
nective tissue outer. Dissector forceps can be use-
First trocar is 12 mm in size which is placed at ful to dissect and enter the loose thin connective
infra-umbilicus by close technique or Hasson tissue around SMV to expose SMV. Middle colic
technique. One 12 mm trocar and two or three vein can drain separately or join with gastroepi-
5 mm trocars are placed as in Fig. 2. ploic vein to SMV. We prefer to leave middle
Laparoscopic Distal Pancreatectomy 351
Fig. 2 Trocar position
mesocolon consists of two peritoneal leaves. One

Pancreas
passes on retroperitoneum in cranial at anterior
surface or inferior border of pancreas; another
runs downward. We need to incise the former at
the site of inferior border of pancreas for mobiliz-
ing. Incision is usually started below pancreatic
body. After that blunt forceps should be applied
to identify the right plane. That is avascular plane.
Mobilization will progress in left direction and
then splenic flexure of colon is mobilized by
dividing splenocolic omentum. Mobilized colon
Fig. 3 SMV and PV exposure is retracted inferiorly to well expose both inferior
border of pancreas and spleen. During mobilizing
route, there are some small vessels going across
colic vein unless it impedes such as in SMA first dissection plane. Hence, an energy device has
approach or some variations. been usually used to provide a clean view.
SMV and portal vein (PV) exposure (Fig. 3) is
slowly developed upward till superior border of
pancreas. This work is recommended under osterior Dissection and Splenic
P
viewing. Expanding our dissection to the left of Vessel Exposure
SMV facilitates this work. During expanding dis-
section, we need to consider vessels near SMV. Following right dissection plane of previous step,
posterior dissection of pancreatic body and tail
occurs. The aim of this step is separation of distal
ransverse Mesocolic and Splenic
T pancreas from retroperitoneal structures and facil-
Flexure of Colon Mobilization itating splenic vessel exposure (Fig. 4). In open
surgery, authors have begun exposing splenic ves-
Mobilization of transverse mesocolon is separat- sels with anterior view from cranial border of pan-
ing it from inferior border of pancreas. Transverse creas. Splenic artery is prior exposed because
splenic vein is located deeper and in caudal which splenic artery are dissected in case of malig-
is covered by pancreatic parenchyma. With lapa- nancy. Partly exposed splenic artery of the pre-
roscopic surgery, this is preferably done with pos- vious step is more dissected and encircled at
terior view after pancreas is taken away from the site of the planned line of pancreatic tran-
retroperitoneum and lifted. By doing this, splenic section. Then, splenic vein is dissected and
vein is first dissected. Circulating these vessels is encircled.
usually combined with anterior dissection later in In LDP with splenectomy, splenic vessels are
the next step. transected. Splenic artery should be first ligated
and transected at the planned pancreatic tran-
section line. Splenic vein is transected sepa-
pper Border of Pancreatic Neck
U rately or together with the pancreas by staplers.
and Celiac Trunk Dissection There are various applicable kinds of vascular
ligation such as vascular staplers, clip, tie, or
Dissection is started at the upper border of pan- suturing.
creatic neck and then proceeded left laterally.
The fat and lymph nodes along common
hepatic artery (CHA), left gastric artery, and Pancreatic Transection
The distal pancreas is divided by a linear stapler

Pancreas (Fig. 5). Although none of the staplers has proved
superior in terms of postoperative pancreatic fis-
tula (POPF), short height staplers are usually
used. Tissue compression when stapling relates
to risk of bleeding and POPF. Gradually increas-
ing pressure with three or four consecutive stairs
should be performed with at least 3 min for each
stair to achieve best tissue compression before
Splenic vessel
transection.
Alternative methods of transecting the pan-
creas is to use ultrasonic shears or electrocautery
Fig. 4 Splenic vessel exposure to divide pancreatic parenchyma. Pancreatic duct
Fig. 5 Pancreatic neck transection using linear stapler

should be identified and ligated or sutured by a aparoscopic Spleen Preserving

L
nonabsorbable monofilament suture. The stump Distal Pancreatectomy
is oversewn with a running suture to secure
bleeding and pancreatic leakage. This technique requires more advanced laparo-
scopic surgical skills (Fig. 7). Operating time
is usually longer than LDP with splenectomy.
Separating Specimen However, postoperative complication rate is
reported lower than LDP with splenectomy.
In this step, LDP with splenectomy is different Moreover, spleen plays a role in immunity in
from LDP without splenectomy. human body. Postoperative infection rate of
spleen preserving was also reported signifi-
cantly decreasing [5–9]. There are two meth-
Laparoscopic Distal ods of preserving spleen. They are splenic
Pancreatectomy with Splenectomy
After splenic vessels and the pancreas are tran-

sected, dissection is continued further to left lateral
direction. Ensuring en bloc dissection with lymph
nodes and fat surrounding pancreas is necessary,
Pancreas
especially for pancreatic cancer or high malignant
potential lesion. After the body and tail of the pan- Splenic vessel
creas is completely separated from retroperito-
neum, splenorenal ligament is exposed and divided
to mobilize the spleen. The specimen is extracted
in a retrieval plastic bag (Fig. 6). Distal pancre-
atectomy with splenectomy, showing splenic
artery ligation and spleen mobilization. Fig. 7 Spleen preserving distal pancreatectomy
a b
Fig. 6 Distal pancreatectomy with splenectomy. (a) Splenic artery ligation, (b) spleen mobilized
vessels saving (Kimura’s technique) and sacri- still controversial to indicate standard LDP for
ficing (Warshaw’s technique). The former pancreatic adenocarcinoma. Standard LDP can
associated lower rate of ischemic spleen. In be done with or without splenectomy.
terms of technical advantages, Warshaw tech-
nique is easier to do.
With Warshaw’s technique, splenic vessels are References
transected two times. First time of transecting is
similar to LDP with splenectomy. After that 1. Cuschieri A, Jakimowicz JJ, van Spreeuwel
J. Laparoscopic distal 70% pancreatectomy and
mobilization of distal pancreas and splenic ves- splenectomy for chronic pancreatitis. Ann Surg.
sels is proceeded to splenic hilum. Then, pancre- 1996;223(3):280–5.
atic tail is separated from splenic hilum. Splenic 2. Björnsson B, Sandström P. Laparoscopic distal pan-
artery and vein are exposed above freed pancre- createctomy for adenocarcinoma of the pancreas.
World J Gastroenterol. 2014;20(37):13402–11.
atic tail. These vessels are divided second time. 3. Postlewait LM, Kooby DA. Laparoscopic distal pan-
The short gastric vessels are preserved. createctomy for adenocarcinoma: safe and reason-
In splenic vessel preserving technique, dissec- able? J Gastrointest Oncol. 2015;6(4):406–17.
tion is performed along splenic vein and artery. 4. Tewari M. Surgery for pancreatic and Periampullary
cancer. Singapore: Springer Nature Singapore Pte
There are direct branches from splenic vessels to Ltd; 2018.
the pancreas. These vessels should be dissected 5. Butturini G, Damoli I, Crepaz L, Malleo G,
meticulously and divided using ultrasonic shears Marchegiani G, Daskalaki D, et al. A prospective
or advanced bipolar energy, if necessary, clips are non-randomised single-center study comparing lapa-
roscopic and robotic distal pancreatectomy. Surg
applied. When uncontrollable bleeding happens, Endosc. 2015;29(11):3163–70.
Warshaw’s technique is an alternative option. 6. Casadei R, Ricci C, D’Ambra M, Marrano N, Alagna
Finally, inspection for bleeding and fluid V, Rega D, et al. Laparoscopic versus open distal pan-
clearance is completed. A drain is positioned createctomy in pancreatic tumours: a case–control
study. Updat Surg. 2010;62(3):171–4.
close to pancreatic stump. Specimen in placed in 7. Mellemkjoer L, Olsen JH, Linet MS, Gridley G,
retreival bag and exteriorized via expanded inci- McLaughlin JK. Cancer risk after splenectomy.
sion of umbilical port or Pfannenstiel incision. Cancer. 1995;75(2):577–83.
8. Pendola F, Gadde R, Ripat C, Sharma R, Picado O, Lobo
L, et al. Distal pancreatectomy for benign and low grade
malignant tumors: short-term postoperative outcomes
Complication and Management of spleen preservation-a systematic review and update
meta-analysis. J Surg Oncol. 2017;115(2):137–43.
Complications are POPF, postpancreatectomy 9. Shoup M, Brennan MF, McWhite K, Leung DH,
Klimstra D, Conlon KC. The value of splenic pres-
hemorrhage (PPH), and delayed gastric emptying. ervation with distal pancreatectomy. Arch Surg
These complications are identified and classified (Chicago, Ill: 1960). 2002;137(2):164–8.
according to consensus of International Study 10. Liao CH, Wu YT, Liu YY, Wang SY, Kang SC, Yeh
Group of Pancreatic Surgery (ISGPS). Among CN, et al. Systemic review of the feasibility and advan-
tage of minimally invasive Pancreaticoduodenectomy.
them, POPF and bleeding are most common [10, World J Surg. 2016;40(5):1218–25.
11]. Management of POPF and PPH are described 11. Chen K, Liu XL, Pan Y, Maher H, Wang XF. Expanding
in “Laparoscopic pancreaticoduodenectomy.” laparoscopic pancreaticoduodenectomy to pancreatic-
head and periampullary malignancy: major findings
based on systematic review and meta-analysis. BMC
Gastroenterol. 2018;18(1):102.
Summary
Standard laparoscopic distal pancreatectomy is

now indicated for both benign and premalignant
lesions located in body or tail of pancreas. It is
Laparoscopic
Pancreaticoduodenectomy
Introduction complications can happen if these major vascular

structures are injured.
Evolution and difficulties of Laparoscopic In recent years, outcome of LPD has been sig-
pancreaticoduodenectomy. nificantly improved owing to developments of
Pancreaticoduodenectomy (PD), understood surgical technique, medicine and equipment, and
as radical pancreaticoduodenal resection at pres- energy devices, for example. LPD has become
ent, was popularized by Allen O. Whipple and more common all over the world. However, this
colleagues [1]. At that stage, this procedure is is still a challenging procedure.
associated with a high rate of morbidity and mor- LPD consists typically of standard LPD, LPD
tality. With natural evolution, developments in with arterial first approach, and LDP with superior
equipment and technically surgical skill had been mesenteric-portal vein resection. This chapter’s
appearing. Gagner and Pomp [2] successfully purpose is to describe technically the former.
performed laparoscopic pancreaticoduodenec-
tomy (LPD) in 1994. The procedure’s popular-
ization was still low, especially over the next Indications
decade. This is due to high rate of postoperative
complications and technical difficulties. LPD is generally indicated for below conditions:
Pancreatic head and duodenum are located deeply
in retroperitoneal space and are close to major 1. Resectable and borderline resectable periam-
vascular structures. These result in difficulties in pullary cancers
performing LPD. Moreover, life-threatening 2. Targeting of malignant pancreatic head neo-
plasms (IPMN)
3. Chronic pancreatitis with inflammatory mass
L. Q. A. Tuan (*) in pancreatic head
Department of Hepatobiliary and Pancreatic Surgery, 4. Benign periampullary neoplasms not amena-
University Medical Center, Minimally Invasive ble to local resection
e-mail: tuan.lqa@umc.edu.vn Patient Selection
P. M. Hai
Department of Hepatobiliary and Pancreatic Surgery, Theoretically, most indicated PD is able to per-
University Medical Center, form LPD. Because of certain limitations as pro-
Ho Chi Minh city, Vietnam ceeding LPD such as higher abdominal pressure
https://doi.org/10.1007/978-981-19-3755-2_52
which can cause consequences for respiratory and Technique

cardiac systems. Because LPD operating time is
long, patients with severe respiratory and cardiac There are two main phases included in laparo-
disease should be eliminated. Apart from this, vas- scopic pancreaticoduodenectomy. They are
cular resection and reconstruction require a high resection and reconstruction.
level of laparoscopic surgical skills, longer time
and they can cause more blood loss as well. Trocar Placement
Although authors can do LPD with borderline First trocar is 12 mm in size which is placed at
resectable tumors belong to periampullary pathol- umbilicus’ left side by Hasson technique.
ogies, other authors have recommended that bor- One 12 mm trocar and three 5 mm trocars are
derline resectable tumors are only performed at a placed as in Fig. 2.
few specialized centers; indication for LPD in can-
cer patients should be limited at resectable stage.
Procedure
Generally, there are two main procedures in clas- Nurse

sification. One is classic PD called Kausch-
Whipple. Another one is pyloric preservation PD
(PPPD) which was described by Longmire and
Traverso. Both can be done by a minimally inva- Surgeon Assistant
sive approach such as laparoscopic surgery.

O Camera man
Appropriate operating room may require a flexible

Fig. 1 OT setup
table, cautery system, and energy system. Ideally,
there are two monitors located at the head of the
bed over both shoulders’ side. One is for the sur-
geon and scrub nurse and another is for assistants.
When lack of facility, given just one monitor, the
placement should be on the left side of the patient.
Patient is placed in supine with slight head up.
With head up, we can have better view resulting
from gravity retraction. Patient’s legs should be
split to make space for cameraman. Arms are
tucked to create free spaces for surgeon, assis-
tants, and scrub nurse’s activities.
The main surgeon and scrub nurse are posi-
tioned on the patient’s right side. The first assis-
tant’s (cameraman) position is between patient’s
legs and second assistant stands on the left side.
The back table is set up on the right side of
patient, above the scrub nurse. The personnel is
descried as in Fig. 1. Fig. 2 Port placement
Laparoscopic Pancreaticoduodenectomy 359
Inspection
Staging is very important in case of malignant or
suspected malignant lesions. This is a mandatory
step. Abdominal inspection is performed to
assess liver, peritoneal, and mesenteric metasta-
ses. Beside this, we can assess resectability of
tumor.
Dissection Phase
There are different approaches for LPD. We usu-

ally use clockwise approach for dissection phase.
However, all patients were not applied the same
kind of approach. It depended on proper situa-
tion. In case of a tumor located in uncinate pro- Fig. 3 Standard lymphadenectomy during PD
cess, we used superior mesenteric artery first
approach. Clockwise approach includes below num. Moreover, meticulous dissecting is
steps. Before these steps are described in detail, it required. Greater omentum can become partly
is necessary to consider levels of lymphadenec- ischemic after dividing gastrocolic ligament but
tomy in LPD. There are three levels of harvesting we do not need to resect it mostly.
lymph nodes, but we only focus on standard Superior mesenteric vein (SMV) is dissected
lymphadenectomy which is recommended to per- at inferior pancreatic border (Fig. 4). Right gas-
form routinely at present. troepiploic and middle colic vein are important
A consensus statement by the International landmarks. SMV is covered by a thin layer called
Study Group on Pancreatic Surgery (ISGPS) was adventitial tissue and loose thin connective tissue
published in 2014 [3]. “After evaluating all the outer. Dissector forceps can be useful to dissect
available literature and the expert opinions dur- and enter the loose thin connective tissue around
ing the consensus meeting, a clear definition of a SMV to expose SMV. Middle colic vein can drain
standard lymphadenectomy was reached: A stan- separately or join with gastroepiploic vein to
dard lymphadenectomy should include Ln sta- SMV. We prefer to leave middle colic vein unless
tions 5, 6, 8a, 12b1, 12b2, 12c, 13a, 13b, 14a it impedes such as in SMA first approach or some
right lateral side, 14b right lateral side, 17a, and variations. Gastroepiploic vein must be ligated at
17b” (Fig. 3). the site draining to SMV as it drains separately.
When gastroepiploic and superior right colic vein
I nfra-pancreatic Superior Mesenteric form gastrocolic trunk of Henle, the latter should
Vein Exposure be preserved.
After abdomen is carefully explored and signs of SMV and portal vein (PV) exposures are
advanced stage are not found, the lesser sac is slowly developed upward till superior border of
entered by dividing gastrocolic ligament below pancreas. This work is recommended under
the level of gastroepiploic vessels. Gastrocolic viewing. Expanding our dissection to the left of
ligament should be divided from the left side to SMV facilitates this work. During expanding dis-
the duodenum to create enough space for work- section, we need to consider vessels nearby SMV.
ing around head and body of pancreas. During
this, transverse mesocolic vessels can be injured xtended Kocher Maneuver
E
because of adhesion, especially at the site of pan- Right border of SMV is used to follow to push
creatic head. Avoiding these consequences, tips transverse mesocolon away from pancreatic head.
are following gastroepiploic vessels and duode- Beside gastroepiploic and anterior pancreatico-
Pancreas
SMV
IVC
Fig. 4 Infra-pancreatic superior mesenteric vein (SMV) Fig. 6 Kocher maneuver

exposure
node group 5 and 6 will be left to remove en bloc
with pancreatic head. For laparoscopic classic
PD, antrectomy is performed at the level of third
or fourth transverse vein on lesser curvature and
at the confluence of the gastroepiploic veins on
greater curvature. We use stapler for this step.
SMV
pper Border of Pancreatic Neck

U
some small vessels Dissection and Gastroduodenal Artery
Ligation
In laparoscopic PD, duodenal or antral transec-
Fig. 5 Some small branches across dissecting plane tion (step 3) should be done prior this step and
next step (dissection of porta hepatis) like outline
in this chapter. In the condition of open PD, step
duodenal vein, there are some small vessels across 3 is usually performed when ability of radical
this plane (Fig. 5). They usually cause bleeding tumor resection is ensured. This means step 3 has
during dissecting this plane that is difficult to con- to follow step 4, 5, and 6. The explanation is
trol. Sharp dissection with energy devices shows because in LPD all laparoscopic instruments go
effectively. Then duodenum part three and part upward from the ports and direction of dissection
four are separated from transverse mesocolon. is in cephalad as well. Thus, surgical viewing
In laparoscopic surgery, it is easier for Kocher becomes better after completing step 3 (Fig. 7).
maneuver if this is dissected cephalad. Extended One more important tip to have good exposure to
Kocher maneuver is completed when not only this area is liver retractor. We prefer liver retrac-
duodenum, pancreatic head, and uncinate are tor as in Fig. 8.
separated from retroperitoneum but inferior vena Anatomical variations may lead to inadvertent
cava (IVC), left renal vein, and SMA are also missing. Most of the major variations such as
exposed (Fig. 6). hepatic or gastroduodenal arterial anomalies,
SMA, and bile duct variations are well identified
uodenal or Antral Transection
D on CT scan preoperatively. Among them, we
Pylorus preserving pancreaticoduodenectomy need to care with accessory or replaced HA due
has been usually performed if signs of duodenal to easily advertently missing (Fig. 9).
invasion have not appeared. It was preferred We usually started at upper border of pancre-
although delayed gastric empty was reported atic neck by incising the fascia and taking away
higher than classic PD. large lymph nodes along common hepatic artery
It is similar to open surgery duodenum tran- (CHA), lymph node group 8a. As a result, CHA
sected below pylorus 2–3 cm in LPPPD. Lymph was exposed. Follow CHA to extend lymphade-
a b
Duoden
Pancreas Pancreas
Fig. 7 Difference of surgical view between before (a) and after (b) duodenal or antral transection in laparoscopic PD
a b
Fig. 8 Liver retractor: before (a) and after (b)
Fig. 9 Accessory or replaced right HA
nectomy bilaterally. According to standard lymph- ligation, we prefer to tie it with suture 2.0 as Vicryl
adenectomy, lymph node dissection is extended to or silk. Supra-duodenal branches should be divided
left gastric artery (LGA) at level of Celiac trunk to make a free space enough. Checking by bulldog
in left direction. It is taken into consideration of before dividing GDA is necessary as in Fig. 10.
preserving left gastric vein which drains to PV or
PV–SMV junction or splenic vein. Continuing dis- issection of Porta Hepatis
D
section toward right side, right gastric artery and Dissection of porta hepatis is also one part of
GDA are exposed clearly and ligated. For GDA lymphadenectomy. First of this step is separation
SMV
GDA
Fig. 11 Clamping bile duct before dividing

Fig. 10 Checking by using Bulldog before ligating GDA
picious invasive SMA. This usually happens with

of fascia covering anterior porta hepatis to remove tumors located in uncinate process. This is the
all fat and fascia around common hepatic duct reason why authors advise to perform uncinate
(CHD), common bile duct (CBD), and cystic duct dissection before pancreatic neck dissection,
en bloc with CBD and gallbladder. These consist especially for open surgery.
of lymph node groups namely 12b1, 12b2, and For uncinate dissection, Treitz ligament is
12c belonging to the Japanese classification. After divided to give advantages for retractor duode-
CBD, gallbladder and around tissue are taken num and small bowel right laterally. Small
down, PV is exposed. Despite not being included venous branches draining to first jejunal vein
in standard lymphadenectomy definition, all fat and inferior pancreatoduodenal vein are ligation
and fascia surrounding HA and PV (group 12a to free SMV. Clip and energic devices such as
and 12p) are practically taken away. These will thunder beat and harmonic scalpel show effec-
be removed en bloc with lymph node group 8a, tively. First jejunal vein which curves postero-
pancreatic head, bile duct, and duodenum at last medially from the right side of SMV to course
dissecting step below. Although anatomical varia- then posterior to SMA is usually protected. With
tions have been checked preoperatively, replaced our experience, if the ability of resection is
or accessory right hepatic artery running right lat- almost certain, uncinate dissection will become
eroposterior to CBD and CHD should be found easier and more advantageous after pancreatic
during dissection of tissue surrounding PV and neck transection.
HA. Proximal stump of bile duct should be tem- Regarding pancreatic neck transection, tunnel
porarily clamped by a bulldog and distal stump under pancreatic neck which is created partly at
of bile duct should be ligation as well to pre- the above steps is continued to complete. One
vent bile leakage as in Fig. 11. Biliary culture is tape is passed through this tunnel to lift pancre-
recommended. atic neck as transecting. After that pancreatic
neck is transected at the level of SMV—PV.
ancreatic Neck Transection, Uncinate
P Continue ligation of small branches draining
Dissection, and SMV, SMA Separation to SMV and PV, usually from 3–5, to free com-
Pancreatic neck transection is irreversible step on pletely SMV and PV as well. Then, SMV and PV
PD. Hence, it is usually completed when we are retracted left laterally to facilitate exposure of
believe that ability of doing PD is certain. This SMA wherein inferior pancreatic duodenal and
means SMA is able to separate from the tumor. first jejunal arteries are found. Inferior pancreatic
We can check this by preoperative abdominal CT duodenal artery (IPDA) may be divided in this
scan in most cases. However, we will get diffi- step (Fig. 12) while first jejunal artery is usually
culty in suspicious cases. Actually, sureness is protected. However, lymph nodes at origin of the
only achieved when we do arterial first approach. latter should be harvested (Fig. 13) showing
Arterial first approach is necessary in case of sus- SMV and SMA separation.
Reconstruction Phase
Pancreatoenteric Reconstruction
At present, there is a range of procedures to do
pancreatoenteric anastomosis. They are typically
SMV
grouped into three main types with similar char-
acteristics each. They are pancreaticogastrostomy,
duct to mucosa pancreatojejunostomy (with or
IPDA without parenchymal sutures), and invaginating
pancreatojejunostomy. Although they are studied
Fig. 12 Ligation of IPDA extensively, no kind is offered clearly superior to
others in terms of improved outcomes [4–13]. Our
team is in favor of end-to-side, two layers duct to
mucosa pancreatojejunostomy.
Firstly, residual stump of jejunum is passed
through transverse mesocolon where Treitz’s liga-
SMV
ment is divided. It is brought and placed close to
pancreatic remnant. The latter is dissected to free
approximately 1 cm from cut edge. Slowly absorb-
able suture monofilaments or bar sutures with 4.0
SMA
size are used for posterior parenchymal layer with
continuous stitches. Next step is to open a hole at
intestinal wall. Diameter of hole is equal to that of
Fig. 13 SMV, SMA separation pancreatic duct. Then duct to mucosa suture is per-
formed by interrupted stitches with absorbable
suture (such as PDS) 4.0 or 5.0. We usually use an
internal stent (Fig. 15) to ensure duct to mucosa
4 pancreatojejunostomy working better and to pre-
5
vent obstruction as well. Suturing to close anterior
3
2 pancreatic parenchyma and jejunum is similar to
posterior layer. Suction and irritation around pan-
1
creatic anastomosis are performed carefully. This
will be repeated once after completing hepaticoje-
junostomy to prepare for collecting fluid around
pancreatic anastomosis. This fluid will be exam-
Fig. 14 After specimen removal in case of replaced RHA

delivering from SMA (1: IV, 2: SMA, 3: SMV, 4: pan-
creas, 5: replaced RHA)
Jejunal Transection and Specimen

Removal
Jejunum is transected by a stapler about 10 cm
from Treitz flexure. Mesentery of proximal small
bowel and connective tissue at the right side of Stent
SMA including lymph node group 14a and 14b
are divided from SMA en bloc. Thus, the dissec-
tion phase is completed (Fig. 14). Fig. 15 Pancreaticojejunostomy with internal stent
stay jejunal limb to hilar plate to minimize ten-

sion of hepaticojejunostomy.
b Enteroenteric Reconstruction
Duodenojejunostomy or gastrojejunostomy is
technically easier than pancreatic and hepatic
a
duct anastomoses. Hence, it is not difficult to do
the former with totally laparoscopic surgery.
However, expanding the incision of trocar to
remove specimen (Fig. 18) is inevitable. Authors
Fig. 16 Completed pancreaticojejunostomy (a) and do it extracorporeally to save time instead.
hepaticojejunostomy (b) Finally, checking for coagulation, bile leak-
age, gauze removal, and fluid clearance are com-
pleted. Drains are placed anterior pancreatic
anastomosis and hepaticojejunostomy as well.
Abdominal fascia defects and skin incisions are
closed.
Laparoscopic pancreaticoduodenectomy is a
major surgery. When doing LPD, there will be
Fig. 17 End-to-side hepaticojejunostomy common morbidities like other major surgery but
the complication rate of LPD is higher. Moreover,
ined for amylase concentration which can be used there are complications only related to pancreatic
to evaluate the risk of postoperative pancreatic fis- resection. These can affect severely patients’
tula. In the condition of unfound pancreatic duct health and lead to mortality [14]. Typically, there
due to very small size, we do pancreatojejunos- are three proper complications after doing PD
tomy like above procedure with only parenchymal such as pancreatic fistula (POPF), bleeding, and
layer and bigger opening on jejunum. delayed gastric empty. Among them, POPF and
bleeding have still been big problems [14, 15].
Hepaticojejunal Reconstruction
All three anastomoses including pancreatojeju- ostoperative Pancreatic Fistula
P
nostomy, hepaticojejunostomy, and enteroenteric Postoperative pancreatic fistula (POPF) after
anastomosis are performed with the same loop of LPD was reported at approximately 20% on aver-
jejunum (Fig. 17). End-to-side anastomosis is age [14, 15]. POPF is defined and classified
used for hepaticojejunostomy (Fig. 16). We pre- belong to the International Study Group for
fer 4.0 or 5.0 absorbable sutures for this step. Pancreatic Surgery (ISGPS) 2016 [16]. There are
Continuous suture is used for both posterior and different clinical conditions from asymptomatic
anterior half of hepatic duct’s circumference if its to life-threatening patients. It may lead to further
diameter is upward of 5 mm. In contrast, if complications as inadequate management, for
hepatic duct is less than 5 mm, we usually use example, abdominal abscess, internal bleeding,
interrupted suture. Important attention must be wound infection, sepsis, and mortality.
paid in this step to find the distance between pan- The important key to treat POPF is to recog-
creatic and hepatic duct anastomoses. This is not nize this problem early and to prevent life-
too long to avoid obstruction due to bending. threatening sequela of this. An abdominal
Biliary stent is unnecessary. Authors routinely contrast-enhanced CT scan is necessary to assess
Fig. 18 Specimen
pancreatic anastomosis, fluid collections, signs of these criteria, PPH is classified into grade A,
infected fluids, and intra-abdominal abscess. grade B, and grade C.
Enteral nutrition is demonstrated to associate Being similar to POPF, PPH in patients who
with higher rate of spontaneous fistula closure remain clinically stable is treated by angiographic
than parenteral nutrition in POPF patients. In intervention. Reoperation is needed for cata-
pancreatojejunostomy where anastomosis is iso- strophic hemorrhage that requires rapid gaining
lated from alimentary tract, oral diet is recom- of hemostasis.
mended although fistula is occurring.
Most POPF cases with stable clinical signs
are treated by nonreoperation. The drains bring- Summary
ing well intra-abdominal fluids are remained and
observed carefully. In case of fluid collection or PD can be done feasibly by totally laparoscopic
intra-abdominal abscess, percutaneous or endosurgery. It includes dissection phase and recon-
scopic ultrasonographic intervention is struction phase. However, this is a technically
recommended. difficult procedure. Both require surgeons with
Reoperation is indicated for sepsis shock, pre- advanced laparoscopic skills and experience in
venting sepsis or septic shock. Another indication pancreatic surgery. Although outcomes are sig-
of surgery is infected collection that requires nificantly improved in recent years, the compli-
lavage. Choice of open or laparoscopic surgery as cation rate is still high and management is still
reoperation depends on certain situation and sur- difficult.
geon’s experience.
Bleeding References
According to ISGPS [17], definition of hemor-
rhage after PD, called post-pancreatectomy 1. Whipple AO, Parsons WB, Mullins CR. TREATMENT
OF CARCINOMA OF THE AMPULLA OF
hemorrhage (PPH), is based on three criteria: VATER. Ann Surg. 1935;102(4):763–79.
onset, location, and severity. Regard onset, hem- 2. Gagner M, Pomp A. Laparoscopic pylorus-
orrhage is defined as early and late PPH happen- preserving pancreatoduodenectomy. Surg Endosc.
ing in less or more than 24 h, respectively. 1994;8(5):408–10.
3. Tol JA, Gouma DJ, Bassi C, Dervenis C, Montorsi M,
Turning to location, PPH is defined intraluminal Adham M, et al. Definition of a standard lymphad-
(intra-enteric) and extraluminal (extra-enteric). enectomy in surgery for pancreatic ductal adenocar-
Finally, we have mild and severe PPH. Based on cinoma: a consensus statement by the international
study group on pancreatic surgery (ISGPS). Surgery. PANCreatoduodenectomy (RECOPANC, DRKS

2014;156(3):591–600. 00000767): perioperative and long-term results of a
4. Bassi C, Falconi M, Molinari E, Mantovani W, multicenter randomized controlled trial. Ann Surg.
Butturini G, Gumbs AA, et al. Duct-to-mucosa versus 2016;263(3):440–9.
end-to-side pancreaticojejunostomy reconstruction 11. Liu FB, Chen JM, Geng W, Xie SX, Zhao YJ, Yu
after pancreaticoduodenectomy: results of a prospec- LQ, et al. Pancreaticogastrostomy is associated with
tive randomized trial. Surgery. 2003;134(5):766–71. significantly less pancreatic fistula than pancreati-
5. Berger AC, Howard TJ, Kennedy EP, Sauter PK, cojejunostomy reconstruction after pancreaticoduo-
Bower-Cherry M, Dutkevitch S, et al. Does type of denectomy: a meta-analysis of seven randomized
pancreaticojejunostomy after pancreaticoduodenec- controlled trials. HP. 2015;17(2):123–30.
tomy decrease rate of pancreatic fistula? A random- 12. Menahem B, Guittet L, Mulliri A, Alves A, Lubrano
ized, prospective, dual-institution trial. J Am Coll J. Pancreaticogastrostomy is superior to pancre-
Surg. 2009;208(5):738–47. discussion 47–9 aticojejunostomy for prevention of pancreatic fistula
6. Clerveus M, Morandeira-Rivas A, Picazo-Yeste J, after pancreaticoduodenectomy: an updated meta-
Moreno-Sanz C. Pancreaticogastrostomy versus analysis of randomized controlled trials. Ann Surg.
pancreaticojejunostomy after pancreaticoduode- 2015;261(5):882–7.
nectomy: a systematic review and meta-analysis of 13. Xiong JJ, Tan CL, Szatmary P, Huang W, Ke NW, Hu
randomized controlled trials. J Gastrointest Surg. WM, et al. Meta-analysis of pancreaticogastrostomy
2014;18(9):1693–704. versus pancreaticojejunostomy after pancreaticoduo-
7. El Nakeeb A, El Hemaly M, Askr W, Abd Ellatif M, denectomy. Br J Surg. 2014;101(10):1196–208.
Hamed H, Elghawalby A, et al. Comparative study 14. Liao CH, Wu YT, Liu YY, Wang SY, Kang SC, Yeh
between duct to mucosa and invagination pancre- CN, et al. Systemic review of the feasibility and advan-
aticojejunostomy after pancreaticoduodenectomy: a tage of minimally invasive Pancreaticoduodenectomy.
prospective randomized study. Int J Surg (London, World J Surg. 2016;40(5):1218–25.
England). 2015;16(Pt A):1–6. 15. Chen K, Liu XL, Pan Y, Maher H, Wang XF. Expanding
8. Hallet J, Zih FS, Deobald RG, Scheer AS, Law CH, laparoscopic pancreaticoduodenectomy to pancreatic-
Coburn NG, et al. The impact of pancreaticojejunos- head and periampullary malignancy: major findings
tomy versus pancreaticogastrostomy reconstruction based on systematic review and meta-analysis. BMC
on pancreatic fistula after pancreaticoduodenectomy: Gastroenterol. 2018;18(1):102.
meta-analysis of randomized controlled trials. HPB. 16. Pulvirenti A, Ramera M, Bassi C. Modifications in
2015;17(2):113–22. the international study Group for Pancreatic Surgery
9. Hua J, He Z, Qian D, Meng H, Zhou B, Song Z. Duct-to- (ISGPS) definition of postoperative pancreatic fistula.
mucosa versus invagination Pancreaticojejunostomy Trans Gastroenterol Hepatol. 2017;2(12):107.
following Pancreaticoduodenectomy: a system- 17. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut
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sus pancreatojejunostomy for RECOnstruction after
Part XV
Spleen
Laparoscopic Splenectomy
Marilou B. Fuentes and Davide Lomanto
Laparoscopic splenectomy has gained popularity there is no multiple organ injury that would
as an option for patients having benign and malig- entail a need for laparotomy. Vital signs
nant diseases as well as for trauma patients who should be stable with a BP > 90/60 mmHg and
are stable. Studies have shown that this procedure HR <120 bpm [3]. Failure rate for conserva-
is prone to bleeding but with advanced technology tive management of splenic injury ranges
and good anatomical knowledge of vasculature, from 10 to 40% [4].
the procedure is not only feasible but can be per-
formed safely. Poulin who did the first laparo-
scopic partial splenectomy for ruptured spleen in Contraindications [5, 6]
1995 proved it was possible. The inherent abun-
dant blood supply and proximity of spleen to vital 1. Portal hypertension secondary to liver
organs make it prone to 5–60% complication dur- cirrhosis.
ing its dissection, and hence utmost care and skills 2. Patient who cannot tolerate general
are needed during surgery [1]. anesthesia.
3. Coagulopathy.
Indications [2]
Pre-OP Assessment
1. Benign hematologic diseases—mostly and Management
children.
2. Malignant hematologic diseases. 1. CT scan with vascular reconstruction: Spleen
3. Splenic Cyst. size and volume (maximum diameter) [2, 5].
4. Trauma—a preoperative Computed 2. Triple Vaccination (Hemophilus influenza,
Tomography (CT) scan is essential to assess Pneumococcus pneumonia, and
the grade of splenic injury and to confirm that Meningococcus): 15 days prior to scheduled
surgery or 10 days after emergency surgery.
3. Prophylactic antibiotic upon induction of
anesthesia and continued postoperatively for
M. B. Fuentes (*)
Department of Surgery, The Medical City, at least 24 hours.
Pasig, Philippines 4. Low-dose subcutaneous unfractionated hepa-
D. Lomanto rin prophylaxis.

https://doi.org/10.1007/978-981-19-3755-2_53
370 M. B. Fuentes and D. Lomanto
OT Setup Second 10 mm at left anterior axillary line

below the costal margin or on or below the lower
Instruments edge of palpable spleen.
Working ports: Two 5 mm in the epigastric
Trocars: 12 mm, 10 mm, and two 5 mm (exposing hilum) and along midclavicular line
30° endoscope (retracting spleen) [7, 8].
Electrosurgical devices: electrothermal bipolar,
advanced energy devices (ultrasonic shears,
advanced bipolar) Surgical Technique
Stapler or Clips
Specimen retrieval bag It is best to do diagnostic laparoscopy to look for
an accessory spleen which is common in 10–30%
of the population. Failure to do so may lead to
Position recurrent or persistent thrombocytopenia. 75% of
accessory spleens are located at the splenic
Patient in right lateral decubitus position. hilum, 20% at the tail of the pancreas, and the
remaining 5% at the gastrosplenic, wall of the
stomach and intestines, greater omentum, mesen-
Port Placement Fig. 1 tery, and pelvic area [9].
Optical port:12 mm at umbilical area, 3–4 cm to

the left superiorly.
Fig. 1 Port placement: (1) umbilical area, (2) anterior axillary line, (3) midclavicular line, (4) epigastric
Laparoscopic Splenectomy 371
Approach (b) Posterolateral approach has better visualiza-

tion and access to vessels, the pancreas, and
(a) Anterior approach has the advantage of hav- accessory spleen. This approach facilitates
ing a direct view of the spleen just like what complete mobilization of the spleen by using
is seen in doing open splenectomy. The gravity as a retractor [2, 6, 8]. The splenore-
downside of this approach is poor visualiza- nal and splenocolic ligaments are divided
tion of hilum that may lead to vessel injury followed by dissection of the hilum,
and bleeding [2, 6]. In this technique, spleen approaching it from the lower pole going to
is exposed by downward traction of colon the upper pole (Fig. 4) [6].
and medial retraction of the greater curvature
of the stomach. The lesser sac is entered
through the gastrocolic ligament (Fig. 2). Parenchymal Resection
The left gastroepiploic and short gastric ves-
sels are divided to completely separate stom- (a) Total Splenectomy is indicated for centrally
ach and spleen and subsequent access and located, multifocal tumors and malignancy
clipping of splenic vessels (Fig. 3) [6]. [7]. The drawback of infection and vascular
1.Open the lesser sac.

2.Short gastric vessels divided.
Fig. 2 (1) Open the lesser sac. (2) Short gastric vessels divided
3.Access to splenic vessels
Fig. 3 (3) Access to splenic vessels

and is the technique commonly used for

large splenic vessels [12].
(b) Hilar Transection: The entire splenic hilum
is transected as close as possible to the spleen
and makes operative time shorter as com-
pared to vessel first approach [12].
Complications, Prevention,
and Management
Intraoperative Complications [2]
(a) Bleeding secondary to injury of the hilar ves-

Fig. 4 Divide the splenocolic and splenorenal ligaments sels or splenic capsule. Studies showed that
to expose the hilum. Dissection of the hilum. Free from male sex and spleen measuring >19 cm by
lateral attachments ultrasound are independent risk factors for
intraoperative bleeding [13]. Importance of
complications like thrombosis are noted in crucial exposure, knowledge of variations in
studies. anatomy, and careful dissection of structures
(b) Partial splenectomy: With the latest tools that are the initial step to prevention of bleeding. In
are readily available and modifications of the eventuality of bleeding from parenchyma,
technique for improved visibility of struc- one can apply pressure/packing the area first,
tures, partial splenectomy with the removal of while bleeding from hilar vessels can be man-
the lesion and preservation of function is now aged by clamping/grasping the vessel by a
considered an option for treatment. The upper grasper and applying clips to bleeding vessel.
pole is often preserved for systemic disease When using stapler at the hilum, pedicle
because it is difficult to free from diaphragm should be cleared and the stapler fired under
as compared to dissecting the lower pole from direct vision. Splenic artery can be clipped to
splenic colon flexure.20 This procedure makes reduce the splenic size and make the spleen
use of selective devascularization of the soft for easier extraction [1, 2].
splenic vessels and resection along or 1 cm (b) Organ injury: Chand et al. observed a 15%
inside the ischemic line to prevent bleeding pancreatic injury resulting in pancreatic fis-
[10, 11]. tula. Identification of pancreatic tail and dis-
secting it away from the hilum avoids this
Spleen Remnant Size: 25–30% preserved complication. Bowel injury, as well as dia-
spleen parenchyma allows good immunologic phragmatic injury, can happen during mobi-
response [3, 5]. Studies done by Vasilescu lization of spleen, it is important that these
et al. show that a mean volume of 41.4 cm3 is complications are recognized and addressed
enough to preserve the spleen’s immunologic intraoperatively [1, 2, 10].
function, while Stoher et al. noted it to be at
10 cm3 [10].
Postoperative Complications
Vessel Dissection (a) Postoperative hemorrhage may occur at the

splenic vessels at the tail of the pancreas,
(a) Vessel first: The main trunks of splenic artery short gastric vessels, or trocar sites present-
and vein are identified at the pancreatic tail ing as tachycardia, hypotension, decreasing
Laparoscopic Splenectomy 373
hemoglobin with abdominal distension. lization of the acutely thrombosed portal or

Rapid resuscitation should be done for hemo- mesentery vein.
dynamically unstable patients followed by (d) Respiratory: pneumonia and atelectasis.
exploratory laparotomy for control of bleed- (e) Ileus.
ers. If the patient is stable, may opt to do (f) Hernia: Port site hernias usually develop for
laparoscopy for control of bleeders [1]. incisions larger than 10 mm, which can be pre-
(b) Infection: Subphrenic abscess is a known vented by meticulous suturing of fascia [1].
complication yet is difficult to diagnose
resulting in a delay in management. Patients
will usually present with intermittent fever, Post-Op Care [7]
a chest X-ray may show pleural effusion,
raised diaphragm, or basal atelectasis. An 1. Splenic/Portal vein thrombosis—ultrasound
abdominal CT scan is essential for identifi- screening on seventh postoperative day.
cation and as a guide to percutaneous drain- 2. Antibiotic prophylaxis—oral Penicillin for
age. This complication can be avoided by 2 years after surgery but for a lifetime for
meticulous hemostasis and suctioning of immunosuppressed patients [15].
fluid prior to closure [1]. Pancreatitis is also 3. For ITP patients, platelet count evaluation is
a possibility when there is excessive manip- done 1 month after surgery as Complete
ulation or devascularization of the gland. response (platelet 100,000/mm3 without sple-
Overwhelming Post-Splenectomy Infection nectomy treatment), Partial response (platelet
is seen in 4.4% of cases with a 50–80% mor- levels 30,000/mm3, 100,000/mm3 or at least
tality rate, more common in children and twice the basal level), and Complete unre-
more fatal after splenectomy for hemato- sponsiveness (platelet below 30,000/mm3 or
logic disorders. Immunization with pneu- twofold below basal level) [16].
mococcal vaccine 2 weeks before the 4. Vaccination for patients who had emergency
scheduled surgery is the standard of care and splenectomy is done 14 days after the proce-
for children younger than 5 year old who dure. However, for patients with poor follow-
will undergo splenectomy, pediatricians up, it is best to give the vaccination prior to
advise a daily dose of penicillin until they discharge.
reach the age of 10 [1, 14].
(c) Vascular: Splenic vein thrombosis can be
encountered in 20% of patients who had
splenectomy. his is associated with vague References
abdominal pain and can be documented
using an ultrasound or CT scan. Routine 1. Bhandarkar D, Katara A, et al. Prevention and
Management of Complications of laparoscopic sple-
postoperative ultrasound identifies 6.3–10% nectomy. Indian J Surg. 2011;73(5):324–30. https://
thrombosed portal vein (TPV). The risk of doi.org/10.1007/s12262-011-0331-5.
developing TPV is noted to be at 10–50% in 2. Misiakos E, Bagias G, et al. Laparoscopic splenec-
patients who had laparoscopic splenectomy tomy: current concepts. World J Gastrointest Endosc.
2017;9(9):428–37. https://doi.org/10.4253/wjge.
for myeloproliferative disorder, hemolytic v9.i9.428.
anemia, and thalassemia. To prevent this 3. Li H, Wei Y, et al. Feasibility and safety of emer-
complication, it is advised that splenic vein gency laparoscopic partial splenectomy. Medicine.
should be ligated as close as possible to the 2017;96(16):e6450. https://doi.org/10.1097/
MD.0000000000006450.
mesentery, routine postoperative ultrasound 4. Prasad A, Agarwal N. Laparoscopic splenec-
for high-risk patients. Once detected, the tomy in a case of blunt abdominal trauma. J
patient should receive systemic anticoagula- Minim Access Surg. 2009;5(3):78–81. https://doi.
tion immediately as >90% will have recana- org/10.4103/0972-9941.58503.
5. Somasundaram SK, Massey L, et al. Laparoscopic 12. Radkowiak D, Zychowicz A, et al. Quiet for opti-
splenectomy is emerging ‘gold standard’ treatment mal technique of laparoscopic splenectomy–ves-
even for massive spleens. Ann R Coll Surg Engl. sel first or hilar transection? Videosurgery Miniinv.
2015;97(5):345–8. https://doi.org/10.1308/0035884 2018;13(4):460–8. https://doi.org/10.5114/
14X14055925060479. wiitm.2018.76071.
6. Garzi A, Ardimento G, et al. Laparoscopic splenec- 13. Wysocki M, Radkowiak D, et al. Prediction of techni-
tomy: Postero-lateral approach. Transl Med UniSa. cal difficulties in laparoscopic splenectomy and anal-
2019;20(3):9–12. ysis of risk factors for postoperative complications in
7. de la Villeon B, Le Bian A, et al. Laparoscopic 468 cases. J. Clin. Med. 2018;7(12):547. https://doi.
partial splenectomy: a technical tip. Surg Endosc. org/10.3390/jcm7120547.
2014;29(1):94–9. https://doi.org/10.1007/ 14. Liu G, Fan Y. Feasibility and safety of laparoscopic
s00464-014-3638-z. partial splenectomy: a systematic review. World J
8. Ji B, Wang Y, et al. Anterior versus posterolateral Surg. 2019;43(6):1505–18. https://doi.org/10.1007/
approach for Total laparoscopic splenectomy: com- s00268-019-04946-8.
parative study. Int J. Med. Sci. 2013;10(3):222–9. 15. Leone G, Pizzigallo E. Bacterial infections follow-
https://doi.org/10.7150/ijms.5373. ing splenectomy for malignant and nonmalignant
9. Bajwa SA, Kasi A. Anatomy, abdomen and pelvis, hematologic diseases. Mediterr J Hematol Infect
accessory spleen. Treasure Island (FL): StatPearls Dis. 2015;7(1):e2015057. https://doi.org/10.4084/
Publishing; 2020. MJHID.2015.057.
10. Costi R, Ruiz C, et al. Partial splenectomy: who, 16. Turkoglu A, Oguz A, et al. Laparoscopic splenec-
when and how. A systematic review of the 2130 tomy: clip ligation or en-bloc stapling? Turk J Surg.
published cases. Journal of Pediatric Surgery. 2019;35(4):273–7.
2019;54(8):1527–38.
11. Esposito F, Noviello A, et al. Partial splenectomy: a
case series and systematic review of literature. Ann
Hepatobiliary Pancreat Surg. 2018;22(2):116–27.
Intraoperative Splenic Injuries
Introduction Up to 40% of all splenectomies are performed

for iatrogenic injury. The risk of splenic injury is
Intraoperative splenic injuries can occur in any highest during left hemicolectomy (1–8%), open
abdominal surgical procedure. Reports range antireflux procedures (3–20%), left nephrectomy
from vascular surgeons performing abdominal (4–13%), and during exposure and reconstruc-
aortic aneurysm repairs to thoracic surgeons per- tion of the proximal abdominal aorta and its
forming Nissen fundoplication to urologists per- branches (21–60%). Splenic injury results in pro-
forming radical nephrectomies [1]. Injury to the longed operating time, increased blood loss, and
spleen during laparoscopic urological surgery longer hospital stay. It is also associated with a
has a reported incidence of 0.25% [2]. The two to tenfold increase in infection rate and up to
reported incidence of splenic injury resulting in a doubling of morbidity rates. Mortality rates are
splenectomy during colonic surgery is 1.2–8%. also reported to be higher in patients undergoing
The highest percentage of all incidental splenec- splenectomy for iatrogenic injury [5].
tomies are due to colonic surgeries, primarily to a When splenic injury occurs intraoperatively,
large number of these operations and the close the surgeon is faced with the dilemma of whether
proximity between the colonic splenic flexure to perform immediate splenectomy or treat the
and the spleen [3]. Injuries to the spleen during injury conservatively. The spleen is instrumental
laparoscopic adrenalectomy may be either in immunity, especially with regards to encapsu-
access-related or caused by powerful retraction lated organisms. Splenectomy decreases resis-
and handling of the organ [4]. tance to certain infectious etiologies, necessitating
Splenic injury may occur as a result of two eti- prophylactic immunization. However, conserva-
ologies. The first is due to traction injuries from tive treatment of a splenic laceration can be quite
excessive retraction of the spleen, resulting in a problematic owing to the friable and unforgiving
capsular tear or laceration. This is attributable to nature of the splenic parenchyma, which may
inadequate release of the ligamentous attachment result in delayed hemorrhage and eventual sple-
of the spleen to surrounding structures. The sec- nectomy [2].
ond etiology is due to trauma from the instru-
ments used during surgery.
Management
H. Chua (*) · V. M. Roble II The majority of splenic and liver injuries during
Advanced Minimally Invasive Surgery, Cebu laparoscopic surgery are minor capsular lesions
Doctors’ University Hospital, Cebu, Philippines which usually can be managed laparoscopically
https://doi.org/10.1007/978-981-19-3755-2_54
[6]. Splenic injuries that are dealt with conserva- tor with application of FloSeal and additional
tively will require multiple definitive hemostatic Surgicel is done at the completion of every case,
measures, and direct pressure alone is unlikely pneumoperitoneum is evacuated for 5 min and
to provide durable success [2]. These injuries the site is reinspected to ensure perfect hemosta-
are typically sufficiently controlled with the sis. General surgery consultation is obtained if
combination of pressure and application of oxi- the bleeding does not stop with the application
dized regenerated cellulose (Surgicel), absorb- of argon beam, FloSeal, and Surgicel, or if the
able gelatin sponges (Gelfoam), and fibrin glue bleeding recurs after the 5 min pneumoperito-
(Tissucol) [4]. neum evacuation trial period. Laparoscopic
In a study by Coln et al., Gelfoam was the splenectomy may be required in difficult situa-
least effective in achieving hemostasis. It was tions (Fig. 1) [2]. More extensive lacerations to
also the least satisfactory agent studied from a the spleen may warrant open conversion.
convenience standpoint. Surgicel was much eas-
ier to use than Gelfoam and appeared to achieve
faster hemostasis. Surgicel adhered well when Intraoperative spleen injury
applied to the lacerated surface and occasionally
needed a second layer before hemostasis was
achieved [7]. Place Surgicel on injury;
The use of fibrin sealants for rapid and defin- wait for haemostasis
itive hemostasis for splenic injuries was
described by Canby-Hagino et al. Fibrin sealant
No active Active
achieved adequate immediate hemostasis and bleeding bleeding
each patient recovered without further splenic
bleeding. It is simple to use in the open and lap-
aroscopic approaches [8]. 1) FloSeal
The use of gelatin thrombin granules Finish case 2) Surgicel
(FloSeal), argon beam coagulator, and Surgicel 3) Argon beam
was described by Chung et al. FloSeal consists
of a gelatin matrix and a Thrombin component,
which are mixed together before use. Cross- Active
No active bleeding
bleeding
linked gelatin granules in the matrix swell
approximately 20% on contact with blood or
bodily fluids, slowing blood flow. The coagula- Zero pneumoperitonenum General
tion cascade is activated by the thrombin com- for 5 minutes surgery
ponent to form a firm hemostatic plug. These consultation
two processes combine to effect hemostasis by
tamponade [9]. Argon beam coagulator delivers
radiofrequency electrical energy to tissue across Active
No active bleeding
bleeding
a jet of argon gas, providing noncontact, mono-
polar, electrothermal hemostasis [10]. After
evaluation of the extent of injury, Surgicel is ini-
Complete
tially placed on the injured area to provide procedure
hemostasis. If bleeding does not stop with the
first application of Surgicel. Immediate coagu- Fig. 1 Algorithm for optimal treatment of intraoperative
lation of the area with the argon beam coagula- splenic injury [2]
Intraoperative Splenic Injuries 377
References 7. Coln D. Evaluation of hemostatic agents in

experimental splenic lacerations. Am J Surg.
1983;145(2):145:256.
1. Holubar S. Splenic salvage after intraopera-
8. Canby-Hagino E, Morey A, Jatoi I, Perahia B, Bishoff
tive splenic injury during colectomy. Arch Surg.
J. Fibin sealant treatment of splenic injury during
2009;144(11):1040–5.
open and laparoscopic left radical nephrectomy. J
2. Chung B, Desai MM, Gill IS. Management of intraop-
Urol. 2000;164(6):2004–5.
erative splenic injury during laparoscopic urological
9. Stacey MJ, Rampaul RS, et al. Use of FloSeal matrix
surgery. BJU Int. 2011;108(4):572–6.
hemostatic agent in partial splenectomy after pen-
3. Langevin J, Rothenberger D, Goldberg S. Accidental
etrating trauma. J Trauma. 2008;64(2):507–8.
splenic injury during surgical treatment of the colon and
10. Go PM, Goodman GR, et al. The argon beam coagula-
rectum. Surg Gynecol Obstet. 1984;159(2):139–44.
tor provides rapid hemostasis of experimental hepatic
4. Strebel R, Muntener M, Sulser T. Intraoperative com-
and splenic hemorrhage in anticoagulated dogs. J
plications of laparoscopic adrenalectomy. J Urol.
Trauma. 1991;31(9):1294–300.
2008;26(6):555–60.
5. Cassar K, Munro A. Iatrogenic splenic injury. J R
Collab Surg Edinb. 2002;47(6):731–41.
6. Hedican S. Complications of hand-assisted lapa-
roscopic urologic surgery. J Endourol. 2004;18(4):
387–96.
Part XVI
Inguinal Hernia
Transabdominal Pre-peritoneal
Approach (TAPP)
Introduction
History of inguinal hernia is as old as history of

surgery itself. Bassini in 1887 published his orig-
inal description of inguinal hernia repair with a
later modification to Shouldice repair in 1945.
Two real revolutions which have changed the her-
nia repair completely are the Lichtenstein “ten-
sionless” mesh repair in 1989 and the introduction
of laparoscopic surgery to hernia repair in the
early 1990s [1].
Shortly afterward, surgeons have not only
published their early experiences on laparoscopic Fig. 1 Laparoscopic IPOM for inguinal hernia
intraperitoneal mesh (IPOM) (Fig. 1) repair of
inguinal hernia but also described two major
modifications to it—the transabdominal preperitoneal flap, reduction of hernia sac, place-
peritoneal repair (TAPP) and the totally extra- ment of mesh, and closure of peritoneal flap
peritoneal (TEP) repair. Such is the practice of again [3, 4].
modern science at a brisk pace [2].
Transabdominal Pre-Peritoneal (TAPP) repair,
as compared to its counterpart TEP, provides easy Indications
learning in correlation to peritoneal and pre-
peritoneal anatomy. This technique involves a • Reducible primary inguinal hernia (Figs. 2
diagnostic laparoscopy followed by an incision and 3)
on peritoneum, careful blunt dissection to create • Recurrent inguinal hernia after previous open
repair
• Sliding inguinal hernia
S. Malik (*) • Hernia with adhesions at hernia orifices
Department of Surgery, Allama Iqbal Medical • Alternative to difficult TEP
College, Jinnah Hospital, Lahore, Pakistan
S. Wijerathne
System, Singapore, Singapore

https://doi.org/10.1007/978-981-19-3755-2_55
• Antibiotic prophylaxis
• Empty bladder for primary unilateral inguinal
hernia
• Foley’s catheter for bilateral or recurrent
inguinal hernia.
perative Setup, Patient’s Position,

O
and Trocars Placement
• Monitor position: Position of monitor should

Fig. 2 Right direct inguinal hernia
be at patient’s foot end, contralateral to sur-
geon’s position. The Surgeon stand on the
opposite side of the inguinal Hernia.
• Instrumentation required
–– Veress Needle or Hasson’s Trocar for
access
–– 30° telescope 10 mm
–– Atraumatic Graspers (2) 5 mm
–– Curved Scissors (1) 5 mm
–– Hook diathermy (1) 5 mm
–– Bowel Clamp (1) 5 mm
–– Suction/irrigation device
–– Endostaplers for mesh fixation 5 mm
Fig. 3 Left direct inguinal hernia –– Hemolock Clip applicator (1) 5 mm
–– Endoloop (1) (Optional)
• Patient’s position
Contraindications –– Patient should be in supine position with
Trendelenburg position 15°
• Inability to tolerate general anesthesia –– Surgeon stands on contralateral side of her-
• Clotting disorders nia and assistant stands behind or opposite
• Peritonitis to surgeon
• Incarceration (relative) –– Anesthetist should be reminding of endo-
• COPD tracheal tubing positions due to the risk of
• Previous posterior mesh repair (relative) collision of laparoscope cable with the
• Prostatectomy (relative) tube.
• Previous lower midline surgical incision • Trocars size and position (Fig. 4)
(relative) –– 10–12 mm periumbilical trocar
• Previous pelvic surgery for TAPP –– 2 × 5 mm cannula are inserted on the right
• Ascites and left flank for a good triangulation
Transabdominal Pre-peritoneal Approach (TAPP) 383
• Two 5 mm trocars are inserted on either side

of the camera port.
• The first step is to identify key anatomical
landmarks (Figs. 5 and 6) such as [5]:
CA –– the pubic bone,
OS
–– the medial umbilical ligament
–– the inferior epigastric vessels (IEV)
–– the anterior superior iliac spine (ASIS) by
external palpation
• The definition of the type of hernia is in rela-
SN tion to the IEV (Fig. 7)
–– direct hernia: is medial to IEV
–– indirect hernia: is lateral to IEV
Monitor –– femoral hernia: is medial to the IEV and to
the iliac vessels
Fig. 4 Patient’s and surgical team position; suggested
trocars location
Surgical Technique
• General anesthesia with muscle relaxation is

administered.
• 1–2 cm infraumbilical incision is made.
Peritoneal cavity is entered either by creating
the pneumoperitoneum with Veress needle or
using open technique by Hasson’ Trocar.
Pneumoperitoneum is established with CO2
pressures at 10–12 mmHg
Fig. 5 The anatomy and landmarks of the myopectineal

orifice (MPO) of Fruchaud
Fig. 6 The anatomy and Inf. Epigastric V.

landmarks of the
myopectineal orifice Mm. Transverse Mm. Rectus
(MPO) of Fruchaud Abdominis
Abdominis
Femoral branch Direct

Hernia
Indirect
Hernia
Cooper ligament
Pubis
Femoral
Laterocutaneous N. Hernia
Genito-femoral N. Vas Deferens
Spermatic
Vessel
External
Iliac vessel
too low, then the surgeon may try to push the

mesh down which may crumple the mesh and
ultimately suboptimal positioning.
• The indirect hernia sac is reduced and sepa-
rated from the spermatic cord (Fig. 10).
• Occasionally, large indirect sacs cannot be
completely reduced, and in such cases, the sac
can be divided, and the proximal end should
be ligated with a preformed laparoscopic loop
ligature (Fig. 11). Alternatively, the sac can be
ligated with a suture after ensuring it is empty
and then can be divided distal to the ligated
Fig. 7 Type of hernia in relation to IEV site.
• The final step is the mesh positioning and fixa-
tion. A rolled large pore polypropylene mesh
(10 cm by 15 cm in size) is inserted through
the 10 mm port, and with the use of graspers,
the mesh is placed horizontally covering the
myopectineal orifices from the midline of the
pubis to lateral space of Bogros and inferiorly
2 cm below the pubic arch. The mesh is then
anchored with laparoscopic absorbable tacks
or staplers to Cooper’s ligament and lateral to
the IEV high at the abdominal wall to avoid
the cutaneous nerves. This will help to prevent
any mesh migration especially in case of large
Fig. 8 Reduction of hernia content
direct or indirect hernia. Mesh fixation is not
necessary in smaller inguinal hernia [6]. A
selective fixation for large hernia should be
• The next step is to reduce the hernia content adopted (EHS classification; hernia defect >
into the abdominal cavity (Fig. 8). An atrau- L2 and M2). Tacking should be avoided below
matic grasper or a bowel clamp is preferred to the ileopubic tract and laterally below the
minimize any trauma to the contents of the ASIS where the risk of injury to the genito-
hernia. It is advisable to avoid traction over femoral nerve and lateral femoral-cutaneous
the bowel and should attempt graded external nerve of thigh [7] (Fig. 12).
compression. • Mesh fixation is still a debatable topic. There
• The peritoneal dissection starts laterally below is recommendation for fixation in patients
the ASIS and about 5 cm above the upper limit with recurrent or large hernia (>3 cm). We
of the hernia sac (Fig. 9a, b). The peritoneum suggest fixation in all large hernia during the
is opened towards the midline by using dia- early learning curve [8].
thermy hook or scissors and dissected inferi- • Fibrin glue has been advocated as an alterna-
orly by blunt dissection. Peritoneal flap should tive method of fixation, comparable to tacker
be high enough to allow 2 cm overlap to avoid and several studies have shown similar
exposing the edge of the mesh. If incision is results between stapler fixation and fibrin
First view: 30ºOptic, head down position Peritoneal incision

• The peritoneal incision is placed 3–4
cm above all possible defects from
ASIS to MUL.
Epigastric vessels
Medial
umbilical Wide opening of
ligament
the peritoneum
Vas
deferens ASI
lliac artery Testicular
vessels
a Recommendation: Grade (D)
Fig. 9 (a) Landmarks and incision of the peritoneal flap (black line). (b) Incision of the peritoneal flap using diathermy
hook or scissor
glue with reduced risk of postoperative which can cause injury to the neurovascular
chronic pain [9, 10]. structures located behind the peritoneum
• Last step is adequate hemostasis and the clo- and the mesh. Care must be taken to avoid
sure of the peritoneum flap over the mesh by leaving gaps d uring the closure, as it may
using: expose the mesh to the bowel which may
–– Absorbable Tackers lead to future adhesion formation or even
–– Hemolocks fistulation.
–– Continuous Absorbable suture (Fig. 13) • Fascia at the Infra umbilical 10 mm port site
• It is advisable to close the peritoneal flap must be closed.
with continuous absorbable sutures under • Skin at the two 5 mm port site are closed with
direct vision instead of tackers or staplers absorbable sutures or glue.
INFERIOR EPIGASTRIC
ARTERY HERNIA SAC SEPARTED AND
RETRACTED FROM VAS
STRUCTURES
TRIANGLE
OF
DOOM
Fig. 10 (a) Indirect hernia sac is reduced and separated from the spermatic cord. (b) Indirect hernia sac is reduced and
separated from the spermatic cord Figure
Postoperative Care
• Standard Analgesia
• Discharge the patient when the patient can
ambulate and pass urine
• Avoid activities that require straining for up to
2–4 weeks
Postoperative Complications
and Management [5]
Fig. 11 The Indirect hernia sac is divided and ligated • Seroma
using an endoloop
–– Almost evident in majority
–– Size is important to determine the
outcome
–– Avoid unnecessary dissection
–– Usually gets resolved spontaneously
• Bleeding
–– Injury to inferior epigastric vessels, sper-
matic vessels, and iliac vessels
–– Stop anticoagulation before surgery
–– Careful identification of vessels and
dissection
–– Avoid rough dissection
–– Small hematoma would resolve in weeks,
larger hematoma may require aspiration or
Fig. 12 Placement of an anatomical mesh in pre-
peritoneal space with TAPP
surgical drainage but preferably done few
weeks later to avoid mesh infection
• Acute urinary retention
–– Early mobilization
–– Preoperative counseling
–– Adequate analgesia
–– Foley’s catheter may be inserted if patient
is unable to pass urine after several attempts
• Injury to surrounding structures
–– Good knowledge of groin anatomy in the
extraperitoneal plane is important
–– Injury to vas could be devastating, avoid
holding vas and vessels
–– Care must be taken while parietalization of
the peritoneum
Fig. 13 Continuous absorbable suture is utilized to close
–– Judicious use of surgical energy to avoid
the peritoneal flap
bladder and bowl injury
• Postoperative pain 3. Kavic MS, Roll S. Laparoscopic transabdominal

Preperitoneal hernia repair (TAPP). In: Bendavid R,
–– Careful dissection in triangle of pain Abrahamson J, Arregui ME, Flament JB, Phillips
–– Avoid injury to nerves EH, editors. Abdominal Wall hernias. New York, NY:
–– Absorbable tacking instead of metallic Springer; 2001.
tackers and avoid any fixation over the tri- 4. Bittner R, Arregui ME, Bisgaard T, et al. Guidelines
for laparoscopic (TAPP) and endoscopic (TEP) treat-
angle of pain ment of inguinal hernia [international Endohernia
–– Prefer glue over tackers society (IEHS)]. Surg Endosc. 2011;25(9):2773–843.
• Mesh infection https://doi.org/10.1007/s00464-011-1799-6.
–– Maintain sterility during the entire surgery 5. Lovisetto F, Zonta S, Rota E, Bottero L, Faillace G,
Turra G, Fantini A, Longoni M. Laparoscopic TAPP
–– Non touch technique during handling the hernia repair: surgical phases and complications. Surg
mesh Endosc. 2007;21:646–52.
–– Prophylactic antibiotic 6. Khajanchee YS, Urbach DR, Swanstrom LL. Hansen
–– Careful inspection of surgical site after PD outcomes of laparoscopic herniorrhaphy without
fixation of mesh to the abdominal wall. Surg Endosc.
surgery 2001;15:1102–7.
–– Early explanation of the mesh is advisable 7. Simons MP, Aufenacker B-NM, Bouillot JL,
if mesh infection is suspected Campanelli G, Conze J, Lange D, Fortelny R,
• Recurrence Heikkinen T, Kingsnorth A, Kukleta J, Morales-
Conde S, Nordin P, Schumpelick V, Smedberg S,
–– Look for contralateral orifice where Smietanski M, Weber G, Miserez M. European hernia
possible society guidelines on the treatment of inguinal hernia
–– Adequate dissection in adult patients. Hernia. 2009;13:343–403.
–– Appropriate mesh size 8. Saggar VR. Sarangi R laparoscopic totally extraperi-
toneal repair of inguinal hernia: a policy of selective
–– Proper orientation of mesh placement mesh fixation over a 10-year period. J Laparoendosc
–– Adequate medial coverage and overlap Adv Surg Tech A. 2008;18:209–12.
9. Kathouda N, Mavor E, Friedlander MH, et al. Use
of fibrin sealant for prosthetic mesh fixation laparo-
scopic extraperitoneal inguinal hernia repair. Ann
Conclusion Surg. 2001;233(1):18–25.
10. Olmi S, Scaini A, Erba L, et al. Quantification of
Both techniques of endo-laparoscopic inguinal pain in laparoscopic transabdominal preperitoneal
hernia repair (TEP and TAPP) are comparable in (TAPP) inguinal hernioplasty identifies marked dif-
ference between prosthesis fixation system. Surgery.
terms of the surgical outcomes [11]. Tailored 2007;142(1):40–6.
approach in groin hernia repair by considering 11. McCormack K, Wake B, et al. Transabdominal pre-
patient factors and surgeon’s expertise is peritoneal (TAPP) versus totally extraperitoneal
recommended. (TEP) laparoscopic techniques for inguinal hernia
repair: a systematic review. Cochrane Database Syst
Rev. 2005;25(1):CD004703.
References
1. Lichtenstein IL, Shulman AG, Amid PK, Montllor
MM. The tension-free hernioplasty. Am J Surg.
1989;157:188–93.
2. Schultz LS, Graber JN, Pietrafitta J, Hickok DF. Early
results with laparoscopic inguinal herniorrhaphy are
promising. Clin Laser Mon. 1990;8:103–5.
Totally Extraperitoneal Approach
in Inguinal Hernia Repair
Davide Lomanto and Eva Lourdes Sta Clara
Introduction occult or undiagnosed hernia and it can be use-

ful as a diagnostic tool in an emergency hernia
Inguinal hernia can be repaired endoscopically repair of irreducible cases.
via three methods namely total extraperitoneal
(TEP), transabdominal pre-peritoneal (TAPP),
and the less common intraperitoneal onlay Indications
mesh (IPOM) repair. The first two are widely
utilized for the obvious advantages of lower • Patient with primary or recurrent reducible
recurrence and complication rates, and better inguinal hernia
outcome (less pain, less analgesic reqirement, • Fit for general anesthesia
less surgical site infection, reduced length of
hospital stay, early return to daily activity, etc.)
when compared to the open repair while cover-
Contraindications
ing all the potential hernia site in the myopec-
tineal orifice with a large prosthesis [1, 2]. The
• Not fit for general anesthesia
TEP approach has a lower risk of intra-abdom-
• Acute abdomen with strangulated and infected
inal injury to organs and postoperative adhe-
bowel
sions. On the other hand, in the TAPP approach,
• Respiratory distress
the contralateral side can be examined for
• Pediatric patients
D. Lomanto
Department of Surgery, YLL School of Medicine, Relative Contraindications
E. L. Sta Clara (*) • Irreducible Hernia
Department of Surgery, Asian Hospital Medical • Sliding Hernia
Center, Manila, Philippines • Inguino-scrotal Hernia
Training Officer (UMIST) and Training Committee • Previous prostatectomy or pelvic surgery
Department of Surgery, Cardinal Santos Medical • Previous TEP/TAPP Repair
Deparment of Surgery, Rizal Medical Center,
Manila, Philippines Previous lower abdominal surgery is a relative
Department of Surgery, University of Perpetual Help contraindication. Adhesions can pose difficulty for
Dalta Medical Center, Las Pinas, Philippines the attending surgeon, and thus a surgeon who is
https://doi.org/10.1007/978-981-19-3755-2_56
392 D. Lomanto and E. L. Sta Clara
attempting this should be skilled in doing both TEP Operating Theater Setup
and TAPP. But it should be explained to the patient
that there is also a possibility that the operation can Instruments
be converted to an open approach as deemed neces-
sary by the surgeon. Previous open appendecto- • 10 or 5 mm, 30° angled telescopes.
mies are usually not a problem but requires one to • Trocars
be more careful during the lateral dissection. –– 10 mm Hasson’s trocar
Recurrent hernia from a previous TEP is a rela- –– 5 mm trocar
tive contraindication. This can still be done through • Balloon dissector
TEP depending on the expertise of the surgeon. • Based on the IEHS guidelines, it is recom-
Large inguinoscrotal hernia is also a relative mended to use a balloon dissector when creat-
contraindication depending on the experience of ing the preperitoneal space to decrease operative
the surgeon since there would usually be a dis- time, especially during the learning period,
torted anatomy and limited working space in this when it is difficult to identify the correct pre-
kind of inguinal hernias. peritoneal plane and space [5]. Once the learn-
ing curve is overcomed, to reduce the cost of the
procedure, a blind dissection can be achieved by
Preoperative Preparation swiping the telescope along the midline. A self-
made dissector balloon can be arranged using
A thorough history and physical examination are finger gloves over an irrigation device.
necessary to assess the patient including the fit- • Graspers and atraumatic graspers
ness for general anesthesia. If there is any doubt • Scissors, Hook
in the diagnosis of the inguinal hernia (large • Prosthetic mesh
defect, sliding hernia, multiple recurrent, etc.) it • It is advisable to use a large pore polypropyl-
may be prudent to do a preoperative imaging ene or multifilament polyester mesh with a size
work-up by dynamic ultrasound or CT scan. of at least 10 × 15 cm. Using a smaller mesh
It should also be explained to the patient that will increase the risk of recurrence. However,
there might be a risk of conversion to transab- for larger defects of more than 3–4 cm (L > 3
dominal pre-peritoneal (TAPP) inguinal hernia according to EHS classification [4, 5] it is rec-
repair or open approach depending on the diffi- ommended to use a larger mesh (12 × 17 cm)
culty and safety of the procedure, which is based • Tackers and Fixation devices
on the judgment of the operating surgeon. Risk • According to the IEHS Guidelines, fixation of
for recurrence and complications should also be the mesh is required only in particular cases
properly explained to the patient including vas- like large hernia defect (>3–4 cm) especially in
cular, nerve and vas injury, seroma, mesh infec- direct hernia to avoid translation of the mesh
tion, postoperative chronic pain, etc. [3]. and to reduce the risk of recurrence [5]. Today
Prophylactic antibiotic is recommended in the either absorbable or permanent staplers/tack-
presence of risk factors for wound and mesh infec- ers are utilized to fix the mesh to the Cooper’s
tion based on patient status (advanced age, recur- ligament and to the rectus muscle. Sealants in
rence corticosteroid use, immunosuppressive the form of Fibrin Glue (Tisseel or Tissucol,
conditions, obesity, diabetes, and malignancy) or Baxter USA) or synthetic glue (Liquiband,
surgical factors (contamination, long operation AMS UK; Histoacryl, BBraun, Germany; etc.)
duration, use of drains, urinary catheter) [4, 5]. are also available and several studies have
Patient should also be advised to void prior to shown their efficacy and benefits.
the procedure. However, in cases of complicated • Endoloops
hernias (partially reducible, large defect, and/or • Pre-made loop sutures are useful for closure of
the length of surgery more than 1.5 h) it is advis- inadvertent tears in the peritoneum and ligation
able to insert a urinary catheter, which can be of the hernia sac. Based on the IEHS guidelines,
removed at the end of the procedure. it is recommended to close any peritoneal tears
Totally Extraperitoneal Approach in Inguinal Hernia Repair 393
A 10 mm vertical/horizontal infraumbilical
incision is first done. Subcutaneous tissue is
bluntly dissected to expose the anterior rectus
sheath using (2) S-retractors. The anterior rectus
sheath is then incised, lateral from the midline,
on the ipsilateral side of the hernia. This will
avoid the linea alba and accidentally enter the
peritoneal cavity. Then the rectus muscles are
retracted laterally to expose the posterior rectus
sheath.
Once the preperitoneal plane is entered, there
are few techniques to create the space: (1) the
optical balloon dissector; (2) the Veress’ needle
technique; and (3) the most common blunt dis-
section. Using the trocar with an optical balloon
dissector, the space is created by inflating the
Fig. 1 Surgical team position balloon under vision (Fig. 2). This is the plane
one should maintain and create up to the sym-
to decrease the risk of adhesions which may physis pubis using a gauze, finger, or a dissect-
lead to bowel obstruction. If not available, the ing balloon depending on the preference and
loop can be made using a 50–70 cm absorbable expertise of the surgeon. A Hasson’s trocar is
suture and an extracorporeal Roeder’s knot. then inserted, and the plane is confirmed by
inserting a 30° trocar. The rectus muscle should
be visualized at the anterior area to be in the
Patient and Surgical Team right plane. Insufflation is done with carbon
Positioning dioxide at 8–12 mmHg.
Two 5 mm trocars are then inserted at the mid-
The patient is in a supine position under general line under direct vision to prevent any injury to
anesthesia. The operating table is in a slight the bladder, peritoneum, or bowels. The first
Trendelenberg position (10–15°) with both arms 5 mm trocar is placed three fingerbreadths above
tucked at the sides. The attending surgeon stands at the symphysis pubis. The second 5 mm trocar is
the opposite side of the hernia defect and the assis- then placed in between the Hasson’s trocar and
tant stands beside the attending surgeon at the the first 5 mm trocar (Fig. 3).
cephalad side of the patient (Fig. 1). The nurse then
stands on the same side as the surgeon, near the feet
of the patient. The monitor and video equipment
are then placed at the caudal end of the operating
table which can be midline or slightly ipsilateral to
the defect. Monitors mounted on the boom arm
will be helpful in improving visual space.
Surgical Technique
Entering and Creating

the Preperitoneal Space
There are a few techniques to enter and create the

preperitoneal space: Fig. 2 Ballon dissector
ateral Dissection (Lateral Space

L
of Bogros)
Moving towards the anterior superior iliac

spine (ASIS), in a surgical plane that is below
the inferior epigastric vessels (IEV) and above
the peritoneum, the lateral dissection is made.
This plane is confined by the two layers of the
fascia transversalis. The dissection is contin-
ued by pushing down the peritoneum until the
Fig. 3 Trocar placement psoas muscle can be seen. The lateral space of
Bogros is delineated and cleaned all the way up
to the anterior superior iliac spine. Attention
should be made to avoid dissecting further lat-
erally, beyond the lumbar fascia in the so-
called lateral triangle of pain. This will prevent
injury of the latero-cutaneous and genitofemo-
ral nerves. The thin layer of fat covering the
lateral fascia should be preserved and not skel-
etonized, similar energy and diathermy should
not be used at this level (Figs. 5 and 6). Limits
of the lateral dissection are inferiorly the psoas
muscle, superiorly the ASIS, and cranially the
arcuate line.
Fig. 4 Space of Retzius
Medial Dissection Triangle of

(Retzius or Pre-vesical Space) Sp
er
m
at
ic
pain
ve
s
ren
sse
ls
defe
Once all the working ports are inserted, using

Vas
two atraumatic graspers, the dissection is con-

Triangle of
ducted along the midline, below the rectus mus- doom
cle and towards the pubis arch. The first

landmark, cooper’s ligament should be identified
and is an excellent starting point for dissection.
Fig. 5 Triangle of pain and triangle of doom
Dissection should follow the preperitoneal plane.
Fatty tissue present in the preperitoneal space
should be kept in contact with the inguinal floor
and not with the peritoneum. The dissection
should go 2 cm beyond the symphysis pubis till
the obturator fossa to avoid missing any obtura-
tor hernia and to allow the medial lower corner
of the mesh to be fixated once the space is
deflated (Fig. 4). The limits of the dissection are
medial, 1–2 cm beyond the midline and below
the pubis arch; inferiorly till the peritoneal
reflection is identified at the border with the ret-
roperitoneal space. Fig. 6 Lateral cutaneous nerve at the Space of Bogros
Inf. Expigastric V.
Mm. Transverse us
Andominis ect
m . R minis
M bdo
Femoral branch
A
Direct
Hernia
Indirect nt
me
Hernia ga
er li
op
Co
N.
us
eo
is
N
an
b
al
Pu
Femoral
or
ut
Hernia
m
oc
-fe
ter
it o
ens
La
efer
en
D
Vas
G
Spermatic
Vessel
External lliac vessel Davide Lomanto
Fig. 7 Anatomic Landmarks in Endo-laparoscopic inguinal hernia repair
ernia Sac Identification

H
and Reduction
Once the medial and lateral dissections are

completed (Fig. 7), we should be able to iden-
tify all the hernia defects followed by a proper
hernia sac reduction and repair. This will allow
the surgeon to visualize all the anatomical
landmarks, lessen the risk of injuries, have a
wider space for placing the prosthesis and in
case of
Fig. 8 Myopectineal orifice, left
inadvertent tear of the peritoneum to continue
to work safely without being affected by the
pneumoperitoneum. Hesselblack triangle is a direct hernia. The reduc-
The exposure of the whole Myopectineal tion can be easily achieved by identifying and
Orifice should be made after a complete medial holding the hernia “pseudosac” and dividing it
and lateral dissection followed by the hernia sac from the preperitoneal lipoma and peritoneum.
reduction (Fig. 8). When dissecting the direct hernia, the surgeon
must remain in the correct plane in order to avoid
injuring the bladder if it is part of the hernia.
Hernia Reduction Careful dissection is done at the level of the pubis
arch to avoid injury of the “corona mortis” and
edial or Direct Hernia
M laterally of the iliac vessels and vas deferens. The
In endo-laparoscopic approach, a defect medial to pseudosac is grabbed, and the hernia contents are
the inferior epigastric hernia and at the level of the then reduced.
Femoral Hernia
The reduction of the hernia sac and content is
achieved by gentle traction keeping in mind that
the vessels hide behind the content (Fig. 9).
If the content is not reducible by traction due
to the small size of the defect, it may be neces-
sary to widen the femoral defect by using a hook
diathermy ONLY on the medial-upper side
(Fig. 10). This will facilitate the hernia sac
reduction.
Obturator Hernia Fig. 11 Obturator hernia, left

In the same canal where the obturator vessels are,
it is possible that preperitoneal fat and/or hernia using the medial approach and four simple steps:
sac is within. Gentle traction will allow the reduc- (1) Separate the whole sac and spermatic cord from
tion of the hernia sac (Fig. 11). the iliac vessels; (2) Slim the sac at the level of the
deep ring with a partial reduction of both cord
Indirect Hernia structures and sac; (3) Separate the cord structures
Lateral to the IEV, lies the deep ring and the indi- from the sac on the inferior edge of the sac; and (4)
rect hernia. The standard approach to indirect her- Sac reduction by simple traction. Transection of the
nia repair requires the spermatic structures to be sac may be necessary in cases of long or complete
separated from the hernia sac. This can be achieved sac to minimize injury to the testis by overtraction.
It is suggested to divide the sac using diathermy to
reduce the risk of hematoma and to ligate the proxi-
mal part using pre-made suture loop. Lipoma of the
cord should be fully reduced.
Parietalization of the elements of the cord is
considered sufficient when the peritoneum is dis-
sected inferiorly until at least at the level at which
the vas deferens crosses the external iliac vein
and the iliopsoas muscle is identified.
In women, round ligament of the uterus is usu-
ally adherent to the peritoneum. Transection of
Fig. 9 Femoral hernia, right
the round ligament is then recommended, at least
1 cm proximal to the deep ring to avoid injury of
the genital branch of the genitofemoral nerve at
this location.
It is important to close all peritoneal holes/
tears with absorbable suture loops or plastic clips
(i.e., hem-o-lok, Teleflex Medical, USA) to pre-
vent any internal herniation or adhesion forma-
tion with the mesh.
Mesh Repair
Fig. 10 Widening of the femoral ring using a hook dia- The final step is the hernia repair and it is achieved
thermy at the medial-upper side by covering all the myopectineal orifice with a
synthetic large pore prosthesis of 10 × 15 cm. Complications

The mesh is rolled and inserted through the
10 mm trocar. A “no-touch technique” is manda- Complications can be categorized into intra-
tory to avoid mesh infection. The mesh is opened operative and postoperative complications.
and inserted into the preperitoneal cavity avoid- Intraoperative complications specific to TEP
ing any contact with the skin. The mesh is then occur in about 4–6% of the cases and can be due
placed horizontally and unrolled over the myo- to vascular, visceral, nerve, and spermatic cord
pectineal orifice making sure to cover all the her- structures injury [6–8]. Vascular injuries would
nia sites. One-third of the mesh should be below include injury to the external iliac vessels, infe-
the symphysis pubis, the upper margin reaching rior epigastric vessels, spermatic vessels, or the
the lower trocar medially and laterally lining over vessels over the pubic arch including the corona
the psoas muscle. In bilateral hernias, there mortis veins. The most common is the injury of the
should be a 1–2 cm overlap of the meshes at the IEV and this can be avoided by using the midline
midline. It is important to make sure that no part approach and by inserting all the ports under direct
of the peritoneum is under the mesh to prevent vision. Injury to the major vessels are catastrophic,
any recurrence. The mesh should be placed with- a correct lateral traction of the sac and spermatic
out wrinkles or folds and should not be split to structure with a medial approach may be help-
avoid chronic pain or recurrence. ful in avoiding it. Visceral injuries including but
The mesh is then anchored using tackers or not limited to the bowels and urinary tract can be
sealant to prevent mesh migration and possible reduced by careful dissection and limiting the use
recurrence. Two to three point fixations are nec- of diathermy. Transmitted energy through the thin
essary: the Cooper’s ligament, medial to the infe- peritoneal layer may result in injury of the bowel
rior epigastric vessels at the rectus muscle and if underlying. Patients with previous pelvis surgery,
necessary lateral to the inferior epigastric vessels. sliding hernia, or large inguinoscrotal are at risk
Avoid tackers or stapler fixations below the ilio- for bladder injury, in this case a urinary catheter
pubic tract and too laterally considering a may be necessary. In case of injuries, they can be
15–20% of abnormalities in the nerves path. This managed by an endolaparoscopoic suture repair.
will help prevent any nerve injuries and conse- Nerve injuries can be prevented by accurate lateral
quent postoperative chronic pain. dissection, limiting the number of staplers/tack-
An accurate hemostasis should be guaranteed ers if fixation is needed, and the use of absorbable
if the correct surgical plane is identified. The car- tackers or sealant. Spermatic cord injuries can be
bon dioxide is then released while visualizing that lessened by properly identifying the anatomy and
the mesh is not rolled, and the peritoneum stays in avoiding too much traction of the cord. Tears in
front of the mesh to prevent any recurrence. The the peritoneum can also occur especially during
lateral inferior edge of the mesh can be held with the early stage of the learning curve. All perito-
a grasper, if necessary. The ports are then removed neal tears should be closed by using suture loops
and the anterior rectus sheath incision at the or hem-o-loks.
10 mm trocar site is sutured. The skin incisions Postoperative complication like seroma com-
are then closed with absorbable sutures or glue. monly occur in patients with large direct and
indirect hernia, the seroma usuall appear after
7–10 days and do not require any treatment. It
Postoperative Care may be mistaken for an early recurrence. In prin-
ciple, it should be treated conservatively and will
• Diet, as tolerated, is resumed be reabsorbed spontaneously within 4–6 weeks.
• Analgesia is given (etoricoxib 90 mg daily for However, if it is symptomatic and persists after
3 days) 2 months it is advisable to drain by aspiration and
• Patient is discharged on the same day once in sterile condition. In cases of complex sero-
voiding freely hematoma, an excision after 4–5 months should
• Follow-up is at 1 week, 1, and 3 months be considered.
Early recurrence is usually due to inadequate 4. Simons MP, Aufenacaker T, Bay-Nielsen M, et al.
European Hernia Society guidelines on the treat-
surgical technique and can be due to wrong case ment of inguinal hernia in adult patients. Hernia.
selection for beginners, inadequate fixation of the 2009;13(4):343–403.
mesh, inadequate mesh size, inadequate dissec- 5. Bittner R, Arregui ME, Bisgaard T, et al. Guidelines
tion of the myopectineal orifice, and failure to for laparoscopic (TAPP) and endoscopic (TEP) treat-
ment of inguinal hernia [international EndoHernia
cover unidentified hernia defects [9]. society (IEHS)]. Surg Endosc. 2011;25:2773–843.
6. Tetik C, Arregui ME, Dulucq JL, et al. Complications
and recurrences with laparoscopic repair of groin her-
References nias: a multi-institutional retrospective analysis. Surg
Endosc. 1994;8:1316–23.
7. Kraus MA. Nerve injury during laparoscopic inguinal
1. Memon MA, Cooper NJ, et al. Meta-analysis of ran-
hernia repair. Surg Laparosc Endosc. 1993;3:342–5.
domized clinical trials comparing open and laparoscopic
8. Felix E, Habertson N, Varteian S. Laparoscopic her-
inguinal hernia repair. Br J Surg. 2003;90(12):1479–92.
nioplasty: surgical complications. Surg Endosc.
2. Feliu X, Claveria R, Besora P, et al. Bilateral inguinal
1999;13:328–31.
hernia repair: laparoscopic or open approach? Hernia.
9. Pablo RM, Reusch M, et al. Laparoscopic hernia
2011;15(1):15–8.
repair–complications. JSLS. 1998;2(1):35–40.
3. Lomanto D. Katara Avinash. Managing intraop-
erative complications during totally extraperitoneal
repair of inguinal hernia. Minim Access Surg Sep.
2006;2(3):165–70.
Laparoscopic Management
of Recurrent and Re-recurrent
Hernia
Sajid Malik, James Lee Wai Kit, Sujith Wijerathne,

and Davide Lomanto
Introduction
Despite the best surgical techniques and measures,

we still see recurrence rates between 0.5 and 15%
in the current literature, following primary hernia
repair and this depends on the hernia site, method
of repair as well as circumstances of the timing of
surgery [1]. With such a growing number of
patients presenting with hernia recurrence, it is
imperative that general surgeons are familiar and
comfortable with various modalities of repair [2].
Re-recurrent inguinal hernia is defined as a
recurrence of a hernia which has been repaired at Fig. 1 Patient with recurrent hernia after bilateral open
repair
least twice before at the same site [3] (Fig. 1).
According to the EHS, IEHS Guidelines, and
HerniaSurge Group (2018), endo-laparoscopic
posterior approach is preferred for recurrences with other challenging factors like robotic prosta-
after anterior repair and open anterior approach can tectomy, we presume that in the future we are
be used for recurrence after posterior approach [4]. going to experience more cases of either multiple
As the population is aging, the number of recurrences and recurrence after both anterior
cases done laparoscopically has increased and and posterior repairs in which there is a lack of
data and guidelines to guide surgeons on the
S. Malik (*) choice of treatment [1].
Department of General Surgery, Allama Iqbal We would stress that these cases can be
Medical College, Jinnah Hospital, Lahore, Pakistan extremely challenging in which the failure of a
J. L. W. Kit previous treatment not only leads to a difficult
Minimally Invasive Surgery Centre, National surgery but also to an outcome that can be subop-
University Hospital, Singapore, Singapore
timal and poor for the patients. In our modest
S. Wijerathne opinion, these cases for the best of the patients
System, Singapore, Singapore should be referred and treated by Hernia Centers
of Excellence where expertise and high volume
D. Lomanto
Department of Surgery, YLL School of Medicine, will make the difference [5].

https://doi.org/10.1007/978-981-19-3755-2_57
400 S. Malik et al.
In this chapter, we aim to outline the key should be balanced with the benefits, patient’s
points in the use of endo-laparoscopic techniques expectations and expected outcome, and ulti-
for the repair of recurrent and re-recurrent ingui- mately with the surgeon’s experience [8].
nal hernias, based on our experience at a high-
volume hernia center.
Contraindications
Indications In the repair of hernias, contraindications can be

divided into general contraindications for surgery
Indication for repair of hernia recurrences are due to the risk of anesthesia, specific contraindi-
similar to primary hernia repair. In patients who cations to hernia repair as well as contraindica-
have an asymptomatic recurrence, there is a role tions in the consideration of the modality of
for watchful waiting as the risk of complications hernia repair.
remain low even in the recurrent hernia group [1, Hernia repair in general can be considered as
6]. In patients who are symptomatic, repair mild to moderate risk procedure. Therefore, gen-
should be undertaken after evaluation of the erally, most patients would be fit for the proce-
recurrence with a balanced discussion consider- dure. Furthermore, with the advent of options of
ing the patient’s underlying comorbidities and general, spinal, and even local anesthesia in the
quality of life. Urgent repair should be under- course of the repair, the technique can be tailored
taken in patients who present with complications to minimize the risk of anesthesia, especially in
related to the hernia such as perforation, strangu- patients with very poor underlying comorbidities
lation, or obstruction [6]. (e.g., Poor heart function, poorly controlled car-
Recurrences are usually classified according diovascular risk factors, etc.). However, the sur-
to the timing of the recurrence—immediate, geon needs to also take into consideration the
early, and late. Although there is no consensus extent of surgery for these cases and marry the
with regards to the actual definitions of the tim- type of anesthesia with the extent of surgery indi-
ing and some authors have used a period of cated to ensure a good outcome.
5 years to differentiate between early and late Contraindications related to the repair of her-
recurrences. Immediate recurrences are usually nias would include those who would not benefit
due to technical issues such as excessive intra- from the hernia repair (poor quality of life prior
abdominal pressure or trauma to the repair site, to surgery to begin with and are unaffected by the
as well as the presence of occult hernia which hernia recurrence), lifestyle risk factors for her-
was missed during the initial repair. Early recur- nia development that the patients are unwilling to
rences are generally related to surgeon factors modify which would result in further hernia
with regards to surgical technique, tissue han- recurrence in the future and futility of the current
dling, and the choice of tissue versus mesh repair. repair [9].
Late recurrences are generally due to hernia biol- A specific relative contraindication would be
ogy from patient factors such as age-related the repair of hernias in pregnant patients soon
weakening of the anterior abdominal wall, obe- after delivery. In these patients often the abdomi-
sity, smoking as well as the presence of new risk nal wall is lax due to the pregnancy. Most guide-
factors such as chronic constipation and retention lines recommend delaying elective hernia repair
of urine that can lead to chronic increased abdom- in pregnant patients until at least 4 weeks post-
inal pressure resulting in recurrences [7]. partum to allow for sufficient time for the
For Re-recurrences, multiple factors will abdominal wall to regain sufficient normality
influence the decision on repair: type of previous prior to repair to allow for a meaningful repair
repair, age, comorbidities (DM, obesity, [4, 10].
Diverticular diseases, etc.), concomitant pelvic
surgery. An accurate analysis of all risk factors
Laparoscopic Management of Recurrent and Re-recurrent Hernia 401
Pre-Op Assessment mize trauma and injury to both cutaneous nerves

as well as the cord structures. Previous tissue
All patients undergoing hernia repair should repair offers more flexibility in view of the
undergo appropriate preoperative assessment for absence of a mesh which can potentially compli-
surgery. Evaluation of underlying comorbidities cate the surgical repair of the recurrent hernia due
and preoperative optimization should be performed to adhesions to the mesh [2, 4, 10].
with a referral to anesthesia as required [4].
Specific assessment of the hernia should also
be performed. In patients with recurrent hernia Principles of Recurrent Repair
with complex anatomy or possible complica-
tions, cross-sectional imaging should be per- 1. Approach through virgin tissue planes
formed to further delineate the anatomy as 2. Anticipate scarring and distortion of normal
required in order to assist with planning of the tissue planes
hernia repair. A dedicated Informed Consent 3. Reinforcement of the inguinal floor
should be taken highlighting the risk for bladder 4. Dissection from normal tissue to scarred tis-
injury, bowel injury, and injury to the cord struc- sue and avoiding the use of scarred tissue for
tures including vas deferens transection. repair
A dynamic Ultrasound by an expert radiogra- 5. Tension-free technique for suture lines
pher in hernia may be helpful together with a CT 6. Leave previous mesh in place and incorporate
Scan for more complex or complicated situations the edge of the previous mesh into the new
like inguinoscrotal hernia which are not reducible, repair where possible
previous pelvic surgery or radiotherapy, etc. [11]. 7. Dissection to expose and evaluate all hernia
orifices to avoid missing an occult hernia
8. Adequate mesh size for coverage of all hernia
OT Setup orifices and to prevent rerecurrence
• See setup for inguinal hernias in TAPP or TEP

chapters Challenges and Strategies
• Urinary Catheter for complex recurrent and
re-recurrent cases In case of post open anterior repair, repair of
recurrent hernias can be similar to primary repair
through the posterior approach. In some cases, it
Instrumentations is difficult to reduce the direct or indirect sac if
the prior anterior repair had utilized stitches to
• Standard endo-laparoscopic set for Inguinal plicate the transversalis fascia, inadequate isola-
hernia (see chapter on TEP and TAPP) tion of the sac or if a mesh plug was utilized in
the previous anterior repair to fix a direct hernia.
Adhesions are the main challenge in the repair of
Surgical Technique recurrent hernias. Initiating dissection at a more
anterior location would ensure safer dissection
At present, surgery is the mainstay approach for and a reduction in injury to the vas deferens,
all recurrent and re-recurrent inguinal hernias. corona mortis, or bladder. TEP repair is preferred
The surgical approach is determined by the nature if the necessary expertise is present; however,
of the previous repair (mesh vs nonmesh) as well TAPP is a good alternative option as well in such
as previous approach (anterior vs posterior). The recurrent repairs [10, 11].
main principle is the choice of approach should In cases of re-recurrent hernias, the surgical
avoid the route of previous approach with a pref- technique and related repair can be even more
erence for entry through virgin planes to mini- tricky should there have been prior anterior and
402 S. Malik et al.
posterior repairs during the first two surgeries. In

such cases, one needs to ask what is the best
approach? If you attempt endo-laparoscopic
repair which approach is the best? Is it even
worth the challenges to attempt an endo-
laparoscopic repair for re-recurrent hernias?
Treatment of re-recurrent hernias needs to be
individualized to the patient. Risk and benefit of
the procedure would need to be considered by the
attending surgeon after a thorough discussion
with the patient [12, 13].
In cases where the patient is elderly (e.g.,
more than 80 years old) with multiple comorbidi-
Fig. 2 Medial recurrence after open mesh repair and TEP
ties who presents with an asymptomatic re- mesh repair
recurrent hernia, it is prudent to consider that
conservative management is a viable alternative
given the risk benefit of performing a complex
repair for an asymptomatic patient.
In cases whereby the patient is young, fit, and
healthy with evidence of a re-recurrent hernia after
both an anterior and posterior repair failure, our
recommendation is to perform a transabdominal
posterior approach (TAPP). Using this approach
we are able to make a clear diagnosis of the hernia
type, size, and location of the recurrence. Using
this method we can also understand the reason for
failure having a clear view of the myopectineal Fig. 3 Recurrence with mesh shrinkage
orifices during the procedure. We recommend
using a urinary catheter during the intraoperative
period to keep the urinary bladder decompressed
and to prevent bladder injuries during both recur-
rent and re-recurrent inguinal hernia repairs [14].
In our experience, majority of the recurrences
after multiple previous open anterior repairs are
usually medial recurrences (70–75%) [1] (Fig. 2).
Re-recurrences after both anterior and posterior
repairs are usually because of improper previous
mesh placement, which could be placement of the
mesh too high or the repair of a large direct hernia
(15–20% of the time), resulting in either medial or
Fig. 4 Recurrence due to mesh placed higher on the myo-
lateral recurrences (Figs. 3, 4, 5, 6, and 7).
pectineal orifice
Our recommended approach for such cases
can be outlined below
• Attempt to get a strong medial fixation point
• Initiation of the dissection where the posterior for the next mesh, and if you cannot dissect up
myopectineal orifice of Fruchaud (MPO) is to the Cooper’s ligament because of high risk
not covered by mesh. for bladder injury, then consider overlapping
• Attempt to reduce the hernia sac or excise it. the new mesh to the old and use titanium fixa-
Fig. 5 Medial recurrence after large direct hernia repair Fig. 8 After laparoscopic IPOM Plus repair for re-
and mesh displaced inside the hernia recurrent inguinal hernia
Fig. 6 Rerecurrence after previous TEP mesh repair Fig. 9 Direct Defect Closure as a measure to prevent
recurrence and reduce seroma
Fig. 10 After the closure of medial defect

Fig. 7 Medial recurrence after previous TEP
tion above the pubis arch [15]. Consider an edge of the mesh needs to be sutured to the
Intraperitoneal onlay (IPOM) or transabdomi- peritoneum to prevent further recurrences.
nal partial extraperitoneal mesh placement Close the direct defect using nonabsorbable
(TAPE) and fix it using staplers on top and the sutures (Figs. 9 and 10. Usmani et al. have
upper medial side of the old mesh (Fig. 8). described primary closure of direct inguinal
• Fixing the mesh medially to the Cooper’s liga- hernia defects with a barbed suture (TEP/
ment using tackers in both approaches is TAPP plus technique) which is also supported
important and during IPOM repair the lower and recommended by the International
404 S. Malik et al.
Recurrent Hernia
Previous Anterior Previous Posterior

Repair Repair
Perform Posterior Perform Anterior

Repair Repair
Re-Recurrence
Previous Previous Recurrent

Recurrent Anterior
Antetior/Posterior Posterior/Anterior Anterior/Posterior
Posterior Approach Posterior Approach Posterior Approach

Recommended Recommended Recommended
TAPP Preferred IPOM TAPP Preferred

TEP Selected TEP/TAPP TEP/IPOM Selected
Fig. 11 Algorithm for repair of recurrent and re-recurrent groin hernias
Endohernia Society’s Update of Guidelines in ens, spermatic artery and veins, and iliac ves-
2015 [16]. This technique is known to reduce sels are located.
the incidence of seroma and recurrence rates • Consider distorted anatomy always in the
in large direct inguinal hernia repairs. repair of re-recurrent hernias.
• In some patients, a thin layer of fat may allow • Authors have devised this algorithm which
you a good dissection plan between the mesh can be used to decide on a tailored approach to
and the MPO. The surgeon needs to be extra manage cases of recurrent and re-recurrent
cautious in the lower area where the Vas defer- inguinal hernia (Fig. 11).
Complications and Management 3. Burcharth J, Andresen K, Pommergaard HC, et al.

Recurrence patterns of direct and indirect ingui-
nal hernias in a nationwide population in Denmark.
Complications related to the repair of recurrent Surgery. 2014;155:173–7.
hernias are similar to the complications of repair 4. HerniaSurge group. International guideline for groin
of primary hernias. However, specific to the hernia management. Hernia. 2018;22:1–165. https://
doi.org/10.1007/s10029-017-1668-x.
repair of recurrent hernias, the surgeon should be 5. Bisgaard T, Bay-Nielsen M. Kehlet H re-recurrence
mindful that distorted anatomy, nonvirgin planes, after operation for recurrent inguinal hernia. A nation-
and the presence of possible previous meshes do wide 8-year follow-up study on the role of type or
increase the risk of postoperative pain. Dissection repair. Ann Surg. 2008;247:707–11. https://doi.
org/10.1097/SLA.0b013e31816b18e3.
through previous plans also increases the risk of 6. van den Heuvel BJ, Wijsmuller AR, Fitzgibbons
bowel, bladder, and vessel injury especially RJ. Indications–treatment options for symptomatic
through the posterior approach for recurrent and and asymptomatic patients. In: International guide-
re-recurrent hernias as adhesions would have lines for groin hernia management. Hernia. 2018;22:1–
165. https://doi.org/10.1007/s10029-017-1668-x.
developed from the previous surgery. 7. Siddaiah-Subramanya M, Ashrafi D, Memon B,
Memon MA. Causes of recurrence in laparoscopic
inguinal hernia repair. Hernia. 2018;22:975–86.
Postoperative Care https://doi.org/10.1007/s10029-018-1817-x.
8. Burcharth J. The epidemiology and risk factors for
recurrence after inguinal hernia surgery. Dan Med J.
See chapter on hernia postoperative care. 2014;61:B4846.
9. Murphy BL, Zhang J, Ubl DS, Habermann EB,
Farley DR, Paley K. Surgical trends of groin hernia
repairs performed for recurrence in medicare patients.
Conclusion Hernia. 2018;23:677–83. https://doi.org/10.1007/
s10029-018-1852-7.
Recurrent hernias will become a predictably big- 10. Bittner R, Arregui ME, Bisgaard T, et al. Guidelines
ger problem in the future with the increasing for laparoscopic (TAPP) and endoscopic (TEP) treat-
ment of inguinal hernia [international Endohernia
number of hernia cases being done worldwide. society (IEHS)]. Surg Endosc. 2011;25:2773–843.
Although challenging, it is imperative that gen- 11. Niebuhr H, Pawlak M, Śmietański M. Diagnostic test-
eral surgeons are knowledgeable in various ing modalities. In: International guidelines for groin
approaches of repair to arm themselves with the hernia management. Hernia. 2018;22:1–165. https://
doi.org/10.1007/s10029-017-1668-x.
skills in dealing with these cases based on the ini- 12. Köckerling F, Schug-Pass C. Diagnostic laparoscopy
tial repair approach. Re-recurrences which are as decision tool for re-recurrent inguinal hernia treat-
even more challenging should be referred to spe- ment following open anterior and laparo-endoscopic
cialist hernia centers where possible as their posterior repair. Front Surg. 2017;4:22. https://doi.
org/10.3389/fsurg.2017.00022.
repair might require further advanced 13. Karthikesalingam A, Markar SR, Holt PJE, Praseedom
techniques. RK. Meta-analysis of randomized controlled trials
comparing laparoscopic with open mesh repair of
recurrent inguinal hernia. Br J Surg. 2010;97:4–11.
https://doi.org/10.1002/bjs.6902.
References 14. Tran H, Weyhe D, Berrevoet F, Recurre Weyhe D,
Klinge U. Meshes. In: International guidelines for
1. Schmidt L, Öberg S, Andresen K, Rosenberg groin hernia management. Hernia. 2018;22:1–165.
J. Recurrence rates after repair of inguinal her- https://doi.org/10.1007/s10029-017-1668-x.
nia in women–a systematic review. JAMA Surg. 15. Fortelny RH, Sanders DL, Montgomery A. Mesh
2018;153:1135–42. https://doi.org/10.1001/ fixation. In: International guidelines for groin hernia
jamasurg.2018.3102. management. Hernia. 2018;22:1–165. https://doi.
2. Bullen NL, Massey LH, Antoniou SA, Smart NJ, org/10.1007/s10029-017-1668-x.
Fortelny RH. Open versus laparoscopic mesh repair 16. Usmani F, Wijerathne S, Malik S, et al. Effect of
of primary unilateral uncomplicated inguinal hernia: a direct defect closure during laparoscopic inguinal
systematic review with metaanalysis and trial sequen- hernia repair (“TEP/TAPP plus” technique) on post-
tial analysis. Hernia. 2019;23:461–72. https://doi. operative outcomes. Hernia. 2020;24:167–71. https://
org/10.1007/s10029-019-01989-7. doi.org/10.1007/s10029-019-02036-1.
406 S. Malik et al.
Laparo-Endoscopic Approach
to Complex Inguinal Hernia
[Inguinoscrotal Hernias: Sliding
Hernias]
Rakesh Kumar Gupta and Davide Lomanto
Abbreviations mesh and strangulation, etc. The approach to

these hernias involves a great deal of preoperative
CSTs Component separation techniques preparations and decision-making that is carried
PPP Preoperative progressive pneumoperi- through the operation and postoperative period.
toneum The laparoscopic approach in these cases is fea-
SSIs Surgical site infections sible and with good outcomes provided that the
TAPP Trans abdominal preperitoneal repair surgeon adheres to three M’s; mastery of the
TEP Totally extraperitoneal repair anatomy, meticulous dissection, and modus ope-
randi [2]. No wonder hundreds of procedures
have been described for the treatment of complex
groin hernia. There has been always a concern
Background about whether complex groin hernia can be
treated with laparoscopy or not but more favor-
Very few surgical entities have fascinated sur- able outcomes have been found with laparoscopy
geons over centuries than the complexity of than in open surgery [1].
inguinal hernia repair. Despite being one of the The laparoscopic exploration allows for the
commonest procedures performed, the surgical treatment of incarcerated/strangulated hernias and
fraternity all over the world is still in the quest for the intraoperative diagnosis of occult hernias.
the final word on the best type of repair. Similarly, TAPP appeared to be superior in terms of
treatment of complex groin hernia remains the learning curve, diagnosis of occult hernia, and
same [1]. Complex groin hernia can be defined as the feasibility for incarcerated or strangulated
those with large size, e.g., inguinoscrotal hernia, hernia [3].
sliding hernia, multiple recurrences, infected
Complex Inguinoscrotal Hernias

R. K. Gupta (*)
GS & MIS Unit, Department of Surgery, B.P. Koirala Any hernia that passes beyond the inguinal liga-
Institute of Health Sciences, Dharan, Nepal
ment and extends to the scrotum is termed as
D. Lomanto inguinoscrotal hernia [4, 5]. Scrotal hernia has
National University Singapore, Singapore, Singapore been defined subjectively in the past as scrotal,
e-mail: surdl@nus.edu.sg big scrotal, giant scrotal hernia, etc. Decision to

https://doi.org/10.1007/978-981-19-3755-2_58
408 R. K. Gupta and D. Lomanto
choose the best approach to treat such a hernia is formity in classification of such type of hernias.
not unanimous and is different to treating sur- In this scenario, Ertem M et al. have proposed a
geons. This may be attributed to absence of uni- volumetric classification and based on this, the
surgical procedure [4] (Table 1 and Fig. 1).
Table 1 Choice of surgery in relation to scrotal volume The clinical external measurement will pro-
vide almost exact volume. Normally the CECT
Textile Volume (ml) Surgical procedure
for decision-making for scrotal hernia is not
S 0 - 500 required, except in giant hernias and hernia with
inguino -
T A P P
loss of domain.
anterior
M 500 - 1000
E
Those inguinoscrotal hernias that are hanging
T
L 1000-2000 below the midpoint of the inner thigh when the
posterior
*
scrotal
patient is standing is called as giant inguinal her-
loss of domain
XL *
2000-3000
* * nias [6] (Fig. 2). The term giant scrotal hernia
XXL 3000 <
should be used if the hernia volume is greater
* depends on surgeon’s experience and preference than 1000 ml [4].
Fig. 1 Measurement of scrotum volume in giant hernia Scrotal volume = length * width * depth * 0.52
Scrotal volume can be calculated with the following for-
mula [4]
Laparo-Endoscopic Approach to Complex Inguinal Hernia [Inguinoscrotal Hernias: Sliding Hernias] 409
Fig. 2 Showing giant scrotal hernias Type I, II, and III
Challenges with Complex Indications for Laparoscopic

Inguinoscrotal Hernia Approach
1. Large abdominal wall defects [EHS:M/L ≥ 3]. All complex groin hernia cases are fit for
2. Difficulty in dissecting large hernia sac. surgery.
3. Increased risk of injury to inferior epigastric
artery, testicular vessels, urinary bladder, sig-
moid colon, etc. Contraindications for Laparoscopic
4. Chronic bacterial and fungal skin infections. Approach
5. Loss of domain.
6. Scrotal reconstruction. 1. Prior groin irradiation.
2. Prior pelvic lymph node.
3. Poor candidate for general anesthesia.
4. Giant inguinal hernia type II and III.
Laparoscopy vs. Open
1. Comparison of laparoscopic and Lichtenstein Relative Contraindications

repair in recurrent hernia by Z. Demetreshavili
showed similar operative time (p = 0.068) and 1. Prior laparoscopic herniorrhaphies [9].
postoperative outcomes (infection, seroma,
hematoma) (p = 0.19), less postoperative pain
(p = 0.002) and few sicker days leave in TAPP Preoperative Assessment
(p < 0.001) [7].
2. Laparoscopic repair in cases of sliding hernia 1. Select those patients who give consent for
is safe and feasible with safe outcome. TAPP laparoscopic surgery.
is the preferable method [1]. 2. Conditions predisposing hernia such as con-
stipation, prostatism, pulmonary conditions
We will here be discussing about the laparo- asthma, COPD) should be addressed.
scopic management of the same. Complex groin 3. Adoption of lifestyle modifications such as
hernia is much more difficult to repair through cessation of smoking, exercise, and weight
the anterior approach, not only because of the loss should be encouraged.
large volume to be reduced but also due to the 4. Hernia characteristics such as size, recurrent,
retroperitoneal sliding component that usually bilateral, incarcerated, and strangulation
occurs [8]. should be assessed.
5. Consent should be taken and should be 4. Inferior epigastric vessels may be divided
explained about the increased risk of com- which allow access to the deep internal ring
plications such as seroma, SSI, vascular without injury and also allows the smooth
injury, injury to vas deferens, injury to bowel placement of mesh without wrapping.
and urinary bladder, chronic groin pain, and 5. If hernia is not reducible, ring can be enlarged
recurrence. with anteromedial incision in case of direct
hernia whereas antero-lateral incision in case
As techniques of TEP and TAPP has been of indirect hernia.
already discussed in the previous chapter, in this 6. As sac is quite large in these patients, if com-
chapter an overview of special consideration that plete reduction is not possible, it can be
must be kept in mind while approaching laparo- divided as distal as possible.
scopically will be discussed. 7. In order to check the viability of bowel in
case of TEP, umbilical port is transferred
from preperitoneal position to intraperitoneal
pecial Considerations in Dealing
S position. If there is a need for resection of
Inguinoscrotal Hernias nonviable segment it can be done intraperito-
neally once the repair of hernia is completed
1. Insertion of an additional fourth 5 mm trocar preperitoneally.
may be needed to facilitate the exposure 8. Hybrid approach: Combined laparoscopic
(Fig. 3). approaches and open extraperitoneal
2. Wider preperitoneal space creation is approach when the content of the sac cannot
required. be reduced (Fig. 5).
3. In the case of large and incarcerated hernias, 9. As defect is large, a standard weight mesh
releasing incision on transversalis sling is with wider covering (at least 4–5 cm) is pref-
given with hook cautery at the 10 o’clock erable. The fixation must be favored in such
position (if necessary division of the epigas- cases.
tric vessels may be done) to allow remote 10. A closed suction drain is inserted to prevent
hernial access and increases working space the inevitable incidence of postoperative
and complete reduction of the sac (Fig. 4). seroma (optional).
Fig. 3 Creation of extra port in TEPP Fig. 4 Showing division of transverse sling
Fig. 5 Hybrid approach: combined laparoscopy and open
11. In patients with loss of domain: various : when the mesentery of a retroperitoneal
adjuncts to increase intra-abdominal space is viscus forms part of the wall of the peritoneal
required (i.e., preoperative progressive pneu- sac
moperitoneum, Botulinum toxins, component 3. Type 3: very rare
separation, musculocutaneous flaps, etc.) [6]. : when the viscus itself protrudes without a
peritoneal sac.
Sliding Inguinal Hernia

Challenges with Sliding Hernia
Sliding hernia is very uncommon of all hernia
and contributes 6–8% of all hernia cases [10, 11]. 1. Diagnosis of this hernia is not possible preop-
It is a type of hernia in which the posterior wall of eratively and is usually an intraoperative find-
the sac is not only formed by the parietal perito- ing [11] (Figs. 6 and 7).
neum but also formed by the sigmoid colon with 2. This hernia continues to test the surgeon’s
its mesentery on its left side, caecum on the right understanding of the inguinal canal’s anatomy
side, and often with the portion of bladder in both and technical expertise with a significant rate
sides [10, 12]. Sliding hernia is also called as of complications and a higher rate of recur-
“longstanding hernia” and usually developed in rence [1, 10].
old age patients with a history of long duration
[10, 11]. The surgeon’s experience and comfort level
Bendavid defines a sliding hernia as a “protru- should dictate the choice of the safest repair for
sion through an abdominal wall opening of a retro- the patient. The common techniques and consid-
peritoneal organ, with or without its mesentery, eration of laparoscopic approach [TEP/TAPP] to
with or without an adjacent peritoneal sac” [1, 10]. inguinoscrotal hernias is already discussed in
He describes three types of sliding hernia [1, earlier chapter. We will here be discussing about
10, 11] (Fig. 5). the common pitfalls and the techniques/precau-
tions to deal with it. Laparoscopic repair of slid-
1. Type 1: most common and contributes 95% of ing inguinal hernias is feasible and safe with
sliding hernias impressive results. TAPP approach is preferred
: when a part of the peritoneal sac is made over TEP approach as it allows better identifica-
up by the wall of a viscus, tion of these hernias and offers easier method of
2. Type 2: contributes 5% of sliding hernias sac reduction [1].
5. Usually sliding hernia presents with irreduc-

ibility and also poses difficulty in reduction of
sac, most surgeons prefer TAPP repair.
Moreover, due to the high incidence of recur-
rence, retroperitonealization of the organ is
also recommended which is possible with
TAPP repair.
6. Attempt to separate the sac from the sliding
component should never be made. In case of
difficulty in reduction of sac, it may be divided
beyond the level of the content. The deep
inguinal ring may be cut on superolateral
Fig. 6 Transabdominal view of sliding hernia aspect to facilitate reduction of hernia
contents.
7. The technique of a combined approach to
these difficult cases can simply be another
useful tool in the hernia surgeons’
armamentarium.
8. Do not hesitate to convert laparoscopic
approach to open approach in cases where
there is difficulty in reduction of sac and high
risk of injuries to hernia contents. Stoppa or
Lichtenstein repair may be preferable in some
situations.
To ensure the proper safe landing of both

Fig. 7 Totally extraperitoneal view of sliding hernia patients and surgeons while approaching com-
plex inguinoscrotal hernias laparoscopically, we
strongly advised to follow the 10 golden rules for
Special Considerations [1] a safe MIS inguinal hernia repair [3] (summa-
rized below) along with the abovementioned spe-
1. Foleys’s catheter needs to be inserted after cial considerations.
induction of anesthesia-risk of urinary blad-
der injury is minimized by doing this.
2. After induction of general anesthesia attempt Summary of the Ten Golden Rules [3]
to reduce hernia content should be made. For
irreducible hernias, TAPP should be done 1. Beginning of surgery.
whereas reducible hernia needs to be operated Creation of peritoneal flaps in TAPP.
by TEP. Dissection of preperitoneal space in TEP.
3. Insertion of an additional fourth 5 mm trocar 2. Dissection should always follow the perito-
may be needed to facilitate the exposure. neal plane.
4. As diagnosis of sliding hernia is intraopera- 3. Dissection must be creating enough space to
tive we should see whether the content of the accommodate an adequately sized mesh.
sac is forming the wall of the sac or adhered to 4. External iliac vein must be visible so that
it. moreover sliding hernia may be missed there is no chance of missed femoral
during TEP repair as diagnosis is made only hernias.
after opening of peritoneal sac which is not 5. Parietalization of the elements of the cord
routinely opened in TEP repair. must be sufficient.
6. If needed the distal hernia sac can be tran- 3. Analgesics: injectables/orals,

sected or abandoned in case of complex To improve postoperative pain, infiltration
inguinoscrotal hernias. of trocar site with local anesthesia is
7. The deep inguinal canal should be explored recommended.
in search of lipoma of cord. 4. Thromboprophylaxis: It is recommended that
8. Mesh should properly cover the myopectin- thromboembolic prophylaxis is given accord-
eal orifice with overlap of atleast 3–4 cm. ing to usual routines in patients with risk fac-
9. Surgeon can decide intraoperatively if the tors [9].
mesh needs fixation.
10. Deflation should be done under direct
visualization. Conclusion
There has been little evidence about laparoscopic

Complications approach to complex inguinoscrotal hernias and
sliding inguinal hernias. Before making a bold
Intraoperative claim which technique is the best, more research
should be conducted on this. Laparoscopic
1. Pneumoperitoneum. approach to these hernias is possible with a
2. Injury to inferior epigastric artery. meticulous selection of patients and taking spe-
3. Injury to major vessels. cial considerations into account. The choice of
4. Bowel/Urinary bladder injury. techniques whether TAPP/TEPP depends upon
5. Inability to reduce hernia contents. the surgeon’s choice with which he/she is
comfortable.
Postoperative
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7. Demetrashvili Z, Qerqadze V, Kamkamidze G, et al. org/10.1007/s10029-009-0563-5.
Comparison of lichtenstein and laparoscopic trans- 11. Shoba Rani B, Lokesh K, Sudha MG, Babu YM. A
abdominal preperitoneal repair of recurrent ingui- clinical study on sliding inguinal hernias. J Evid
nal hernias. Int Surg. 2011;96(3):233–8. https://doi. Based Med Healthc. 2015;2(39):6327–43. https://doi.
org/10.9738/CC53.1. org/10.18410/jebmh/2015/870.
8. Beitler JC, Gomes SM, Coelho ACJ, Manso 12. Wang P, Huang Y, Ye J, Gao G, Zhang F, Wu H. Large
JEF. Complex inguinal hernia repairs. Hernia. sliding inguino-scrotal hernia of the urinary bladder.
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s10029-008-0432-7. org/10.1097/MD.0000000000009998.
9. Bittner R, Köckerling F, Fitzgibbons RJ, LeBlanc
KA, Mittal SK, Chowbey P. Laparo-endoscopic her-
Part XVII
Incisional/Ventral Hernia Repair
Laparoscopic Intraperitoneal
Onlay Mesh (IPOM) and IPOM Plus
Introduction higher than the primary occurrence rate; when

repaired for recurrence, rates have been reported
The field of minimally invasive surgery has greater than 50%. Although the advent of pros-
revolutionized the surgical practice by impart- thetic repair has significantly reduced the recur-
ing its ability to avoid major abdominal wall rence rate compared with that of primary suture
incisions [1]. It is expected that laparoscopic repair, it remains in the ranges of 10–24% [3].
surgery might reduce the burden of incisional Gradual decreases in recurrence rates have
hernias which is the most common complica- been realized over the last decade as minimally
tion after abdominal surgery and despite ongo- invasive techniques have been increasingly uti-
ing research in wound closure and reparative lized. For example, in some series, the recurrence
techniques, abdominal incisional hernia rate of initial incisional hernias has been reduced
remains an unresolved problem [1]. The out- to 2–9% [4–6].
come of incisional hernia may have major Moreover, multiple studies demonstrate that
social and economic implications and world- laparoscopic repair of ventral hernia results in a
wide 10–30% of patients undergoing laparot- short length of stay and a quick return to normal
omy will develop an incisional hernia and activities [6]. The recurrence rate after laparo-
subsequent conventional open repair often fails scopic repair of a recurrent hernia ranges between
to adequately address this substantial problem 9% and 12%, which is an improvement when
[2]. The recurrence rate for primary tissue compared with recurrence rates of 20% after con-
repairs may approach the 35% range, which is ventional repair with prosthetic material [6, 7].
Clearly, the laparoscopic approach to repair ven-
tral hernia has significantly improved the man-
agement of this problem. This technique involves
either an intraperitoneal onlay mesh (IPOM) with
or without defect closure (IPOM+) or preperito-
S. Malik (*)
Department of General Surgery, Allama Iqbal neal mesh-placement (PPOM) as in the open sub-
Medical College, Jinnah Hospital, Lahore, Pakistan lay repair [8, 9].
S. Wijerathne This chapter will review the risk factors, indi-
General Surgery and Minimally Invasive Surgery, cations, contraindications, preoperative prepara-
Department of Surgery, National University Health tion, and postoperative care after laparoscopic
System, Singapore, Singapore ventral hernia repair. Additionally, it will discuss
Department of General Surgery, Alexendra Hospita, the complications and steps to avoid these com-
Singapore, Singapore plications for safe practice.
https://doi.org/10.1007/978-981-19-3755-2_59
isk Factors for Primary

R • Eventration
and Recurrent Ventral Hernia • Systemic condition like cirrhosis with caput
medusae
Risk factors for the development of incisional
hernia formation are not well defined and pre-
vention strategies are still a long way to know. Preoperative Preparation
Some well-established systemic and local fac-
tors being reported in many studies are enlisted • Routine blood investigations
as follows [10, 11]. • Bowel Preparation (optional)
• Antibiotic prophylaxis
• CT-Scan (selected cases: recurrent, incarcer-
Systemic Factors ated, etc.) (Fig. 1)
• Pulmonary function (obese)
• obesity • Informed Consent (risk for enterotomy, con-
• diabetes version, seroma, etc.)
• steroid use • DVT prophylaxis
• benign prostatic hypertrophy
• pulmonary disease
• advancwed age T Setup, Patient’s Position,
O
• Male gender and Trocars Placement
• Chronic coughing
• Pregnancy • Monitor position (Fig. 2)
• Weight lifting –– Position of the monitor should be opposite
to the trocars
–– Height and distance should follow standard
Local Factors principles
• Instrumentation required (Fig. 3)
• size of fascial defect –– Veress Needle (Optional)
• type of incision –– Trocars
• method of fascial closure –– Laparoscopic camera unit with 30° tele-
• postoperative hematoma scope 10 mm and 5 mm
• postoperative wound infection –– Atraumatic Graspers (2) 5 mm
–– Curved Scissors (1) 5 mm
Indications
• symptomatic ventral/incisional hernia larger

than 3 cm
• recurrent hernia
Contraindications
• Loss of domain (ventral larger 20 cm)

• Strangulated hernia
• Gangrenous bowl
• Peritonitis
• Intra-abdominal Sepsis Fig. 1 Axial contrast-enhanced reformatted CT image of
the abdomen shows herniation of gut and omental fat
• Infection through a large abdominal defect
Laparoscopic Intraperitoneal Onlay Mesh (IPOM) and IPOM Plus 419
–– Bowel Clamp (2) 5 mm –– Foleys catheter for large, recurrent, inci-

–– Suction/irrigation device sional, or partially or irreducible hernia
–– Energy source preferably LigaSure (1) • Trocars size and position
5 mm –– 12 mm Optical trocar (1)
–– Suture passer/14 G IV Cannula and nonab- –– 5 mm trocars (2)
sorbable suture –– 12 mm port inserted laterally between the
–– Tackers; absorbable or nonabsorbable (for costal margin and the Anterior superior
mesh fixation) iliac spine (ASIS)
–– Clip applier (1) 5 mm (optional) –– 5 mm ports (2) inserted on either side of the
–– Hook diathermy (1) 5 mm (optional) optical trocar
• Patient Position and preparation –– an additional 5 mm port may be required in
–– Standard supine position with both arms an approachable position for the mesh
tucked at the side or on the arm board fixation.
depending on the size and site of hernia
–– Surgeon and Assistant stand on the side of
the patient Surgical Technique
The hernia defect should be marked before the

abdominal cavity is entered (Fig. 4).
First Trocar Insertion
Pneumoperitoneum can be established using

either a Veress needle or a Hasson trocar. The
“open technique” using Hasson’s trocar should
be preferred. In our experience, we establish the
pneumoperitoneum using open Hasson’s tech-
nique which is quite safe entry. Optical trocar
entry should be preferred in obese male with
thick anterior abdominal wall where open tech-
nique would be difficult to achieve (i.e., Opti-
View) (Fig. 5a, b).
The direct view trocar with 0° scope is very
Fig. 2 OT setup useful to avoid bowel injury accessing the abdo-
Fig. 3 Common instruments for IPOM/IPOM+ repair Fig. 4 Marking of defect

a b
Fig. 5 (a) Endoscopic view of Opti-view. (b) Hasson’s technique
men. The first trocar is inserted laterally between

the anterior iliac spine and the subcostal margin
(anterior axillary line). An angled [30° or 45°]
laparoscope, inserted through the 10–12 mm tro-
car, must be utilized to facilitate the visualization
of the anterior abdominal wall.
Working Trocars
Working Trocars placed too close to the edge of

the defect may not allow adequate working space.
Trocars placed too laterally may limit the down-
ward displacement of the instrument handle. Once Fig. 6 Abdominal wall defect with adhesions
the first trocar is inserted, usually two, 5 mm tro-
cars are placed under vision and well lateral to the
defect, on either side of the 10–12 mm port.
Preparing the Defect: Adhesiolysis
If necessary, adhesiolysis is first performed to

clear the margins of the defect and to avoid bowel
injury, the use of diathermy or the ultrasonic dis-
sector should be very careful. Any thermal injury
to intestine could result in catastrophic peritonitis
and result in delayed repair. Despite the fact that
there are plenty of video material available on
social media for using Ultrascission®, LigaSure®,
or Thunderbeat®, authors are c onfident in using
Fig. 7 Adhesiolysis to delineate defect margins
these devices, but with caution, being aware of the
inherent risk. After adhesiolysis is performed a
reduction of hernia contents is started with the External countertraction applied by the assis-
steady hand-over-hand withdrawal of the sac con- tant may facilitate the reduction of the hernia sac
tents (Figs. 6 and 7). contents and can lower the abdominal “ceiling”
to provide better working space. Care must be

taken to avoid excessive tension with grasper to
minimize the risk of intestinal injury at this step.
In rare cases, when incarceration is not possible
to reduce then sharp dissection of the fascial edge
of the defect will facilitate the reduction.
Measurement of Defect Size
Once the margins of the hernia are well delin-

eated and cleared, the defect can be measured by
external palpation or with an intra-abdominal
ruler/suture, or even with a laparoscopic instru- Fig. 8 Four cardinal sutures for mesh anchoring
ment. It is best practice to reduce intra-abdominal
pressure to 6 mmHg in order to get accurate size.
Mesh overlap to defect according to mesh type
should be selected appropriately.
Mesh Size and Choice of Mesh
At the moment, plenty of different types of mesh

are available in the market: Gore-Tex and PTFE
(dual mesh or dual mesh plus), polyester, or poly-
propylene coated with different antiadhesive
agents. All the mesh comes in different sizes and
dimensions. A prosthetic mesh is then tailored to Fig. 9 Transabdominal suture
ensure at least 5 cm overlap of all defect margins.
Distinct “orienting” marks are placed on the
mesh and on the skin (Fig. 6), respectively, to suture repair but a tailored approach should
assist with intra-abdominal orientation. always be practiced before making any decision.
Individual needs and properties should be kept in If suture fixation is decided then sutures
mind for appropriate mesh size and choice. should be placed at four cardinal points of the
mesh (Fig. 8).
For larger prosthesis, additional sutures may
Mesh Fixation be placed between these four sutures. The mesh
is then wrapped around a laparoscopic grasper
Suture, tacking devices, and glue fixation meth- and inserted through the 12 mm trocar. Once
ods are common in practice while authors believe inserted, the mesh is unfurled and oriented cor-
to use a tailor approach for devising a final rectly; the preplaced sutures are pulled transab-
method of mesh fixation based on previous repair, dominally using a suture passer through the
site, size, and other factors. Main idea of fixation previously marked locations (Fig. 9).
is to keep the mesh in contact with the anterior Sutures should not be tied until all sutures are
abdominal wall in order to achieve fibrosis and to pulled, so that the mesh must be adjusted. If we
avoid landing of mesh in the peritoneal cavity to need to readjust the mesh to better cover the her-
prevent complications. Authors recommend to nia defect, the sutures can simply be pulled back
practice absorbable spiral tack fixation over into the abdomen and replaced.
Fig. 10 Spiral AbsorbaTack with safe distance and with

one closest to trocar Fig. 11 Placement of Tranfascial suture with suture
passer to close the defect before mesh placement
Metallic or Absorbable tacks can be used for

fixation but the latter is preferred for less pain,
less seroma, and to prevent other long-term post
complications. Larger meshes require more num-
ber of tacks but it is recommended to keep a safe
distance of 1–1.5 cm between two tacks aiming
for no gaps in between in order to prevent small
bowel obstruction. Selection of length of tack
depends on individual factors like abdominal
wall fats, distance of solid layer (fascial layers)
from mesh, and also type of mesh (prosthetic vs
biological). Spiral tack is 3.9 mm long,
AbsorbaTack® 4.1 mm (functionally), Sorbafix®
6.4 mm, and Securestrap® 7.1 mm. These lengths
are aimed for solid layers like fascia and not just Fig. 12 Intracorporeal continuous repair of defect and
peritoneal or preperitoneal fat. The most difficult divarication as IPOM + repair
part of tack fixation is the one which is the closest
to the trocars. In order to fix properly, it is recom-
mended to place a contralateral trocar or use dif- order to pass nonabsorbable sutures for this
ferent angels with a combination of camera and technique. One length of suture should not be
working ports to achieve solid fixation (Fig. 10). used for more than two passes. Care must be
taken to avoid underlying visceral injury
(Fig. 11).
IPOM+ Intracorporeal continuous repair of defect site
or divarication of recti repair by this technique
In IPOM + additional transfascial sutures should gives an additional benefit to restore anatomy but
be placed transabdominally to ensure defect clo- at the cost of increased post-op complications
sure after sutures passed every 3–5 cm. Suture like pain, seroma, and prolonged immobility
passer or 14 G IV Cannula should be used in (Fig. 12).
Closure Difficult Hernia Location
Once mesh fixation is done, abdominal cavity • For lateral/flank hernias: mobilize the colon
should be explored to look for any bleeding or to get adequate space to place the mesh
injury. All CO2 should allow to exit from the cav- laterally.
ity, and 10 mm trocar site should be closed with • For hernia near the costal margin: sutures
either nonabsorbable suture or PDS. Care must may be passed around the rib/costal cartilage
be taken to avoid any injury or taking abdominal to anchor.
content in sutures. Finger inspection before clo- • For Suprapubic hernia: it is a quite common
sure ensures safety. defect and it is the most difficult and challeng-
ing location to repair either in open or laparo-
scopic repair. Actual experience shows that the
When to Convert best solution is to fix the mesh extraperitoneally
at the Cooper’s ligament using a TAPP-like
• dense bowel adhesion technique.
• adhesion between the bowel and previous
mesh repair
• Enterotomy with important spillage for enteric Complications and Management
fluid
• Unidentified bleeding • Trocar injury
–– Open Hasson’s technique
–– Direct visualization
Postoperative Care –– Care in scarred abdomen
–– Check for injury
• Standard Analgesia • Adhesiolysis leading to injury
• Compressive bandage for 5 post-op days –– Patience in adhesiolysis
• Abdominal binder for 4–6 weeks –– Careful dissection
• Antibiotic therapy if needed –– Use scissors instead of cautery
• Conservative management of the seroma, treat –– Bipolar hemostasis instead of monopolar
by aspiration only if symptomatic (pain) • Post-op ileus or intestinal obstruction
(Fig. 13) –– Larger mesh with more sutures
–– Composite mesh instead of simple poly-
propylene meshes
–– Tackering at periphery of mesh
–– Bring omentum at top of bowl after mesh
placement
• Mesh infection
–– Consider for first case on list
–– Achieve complete sterilization
–– Antibiotic prophylaxis
–– Change gloves before putting in mesh
–– Minimum handling of mesh
–– Nontouch technique for mesh placement
–– New fixation device (absorbable)
–– Mesh with larger pore size
• Seroma/Bleeding
–– Avoid extensive adhesiolysis
Fig. 13 Postoperative large seroma after mesh repair
–– Safe entry into the abdomen with injury to of the enterotomy and if there is important enteral
epigastric vessels spillage the mesh repair should be delayed for
–– Invert sac before closing the defect 1–2 months. Extensive adhesiolysis increases the
–– Less cautery—less infection risk of prolonged ileus, another possible compli-
–– Compression dressing cation that may lengthen the hospital stay.
• Recurrence Lastly, the laparoscopic approach provides
–– Pre-op optimization for systemic condi- additional benefit as a complete exploration of
tions as well as for defects the abdominal cavity, the possibility to add
–– Apply appropriate technique another procedure if needed, an easier adhesioly-
–– Transfascial sutures sis due to the magnification of the view, and a
–– Use larger mesh to overlap 5 cm from lower chronic postoperative abdominal pain
defect because no wide dissection is performed.
–– Centralization of mesh
–– No gaps at mesh edges
• Suture site pain References
–– Liberal but judicious use of local analgesia
–– Adequate post-op analgesia 1. Wright BE, Niskanen BD, Peterson DJ, Ney AL,
Odland MD, Vancamp J, Zera RT, Rodriguez
–– Use glue where preferable to close skin JL. Laparoscopic ventral hernia: are there competitive
–– Adequate IV analgesia advantages over traditional methods of repair? Annals
–– Abdominal binder Surg. 2002;68:291–5.
• Missed or delayed bowel injury 2. Söderbäck H, Gunnarsson U, Hellman P, Sandblom
G. Incisional hernia after surgery for colorectal can-
–– Use atraumatic graspers cer: a population-based register study. Int J Color Dis.
–– Careful inspection of bowel and other 2018;33(10):1411–7.
structures 3. Misiakos EP, Patapis P, Zavras N, Tzanetis P,
–– Gentle manipulation of bowel, if needed Machairas A. Current trends in laparoscopic ventral
hernia repair. JSLS. 2015;19(3):e2015.00048. https://
then hold mesentery instead of bowel itself doi.org/10.4293/JSLS.2015.00048.
–– Avoid energy devices in the vicinity of 4. Luijendijk RW, Hop WC, van den Tol MP, de Lange
bowel DC, Braaksma MM, JN IJ, et al. A comparison of
–– Careful inspection at end of the procedure suture repair with mesh repair for incisional hernia. N
Engl J Med. 2000;343:392–8.
–– Re-laparoscope if in doubt 5. Mudge M, Hughes LE. Incisional hernia: a 10-year
prospective study of incidence and attitudes. Br J
Surg. 1985;72:70–1.
Clinical Results 6. Köckerling F. Recurrent Incisional hernia repair-
an overview. Front Surg. 2019;6:26. https://doi.

org/10.3389/fsurg.2019.00026.
Since its introduction in 1992, the laparoscopic 7. LeBlanc KA. Booth WV laparoscopic repair of inci-
approach has achieved better outcomes than the sional abdominal hernias using expanded polytet-
historical conventional open approach. Patients rauoroethylene: preliminary findings. Surg Laparosc
Endosc. 1993;3:39–41.
have also the benefits associated with MIS 8. Heniford BT, Park A, Ramshaw BJ, Voeller
approach such as less pain, shorter length of hos- G. Laparoscopic repair of ventral hernias: nine years'
pital stay, and less blood loss [12, 13]. experience with 850 consecutive hernias. Ann Surg.
In several series, for laparoscopic ventral her- 2003;238(3):391–9. discussion 399–400
9. Bittner R, et al. Guidelines for laparoscopic treat-
nia repair the length of stay in the hospital ranges ment of ventral and incisional abdominal wall
between 1 and 3 days, the operating time for lap- hernias (international Endohernia society (IEHS))-
aroscopic repair is less than the conventional part 1. Surg Endosc. 2014;28(1):2–29. https://doi.
repair by as much as 30–40 min and the recur- org/10.1007/s00464-013-3170-6.
10. Hoer J, Lawong G, Klinge U, Schumpelick V. Factors
rence rate is significantly reduced around 2–8% influencing the development of incisional hernia. A
[13, 14]. Intraoperative complications like enter- retrospective study of 2983 laparotomy patients over
otomies should be managed by immediate repair a period of 10 years. Der Chirurg; Zeitschrift fur alle
Gebiete der operativen Medizen. 2002;73(5):474–80. 13. Lomanto D, Iyer SG, Shabbir A, Cheah WK. C lapa-
https://doi.org/10.1007/s00104-002-0425-5. roscopic versus open ventral hernia mesh repair: a
11. Kokotovic D, Bisgaard T, Helgstrand F. Long-term prospective study. Surg Endosc. 2006;20(7):1030–5.
recurrence and complications associated with elective 14. Pierce RA, Spitler JA, Frisella MA, et al. Pooled
incisional hernia repair. JAMA. 2016;316(15):1575– data analysis of laparoscopic vs open ventral hernia
82. https://doi.org/10.1001/jama.2016.15217. repair: 14 years of patient data accrual. Surg Endosc.
12. Pradeep CK, Sharma A, Mehrotra M, Khullar R, Soni 2007;21:378–86.
V, Baijal M. Laparoscopic repair of ventral/incisional
hernias. J Minimal Access Surg. 2006;2:192–8.
Extraperitoneal Ventral Hernia
Repair
Introduction [4]. MILOS permits insertion of a large mesh in

the retromuscular or preperitoneal space and ana-
“Bridged-IPOM” of Leblanc has been introduced tomical reconstruction of the abdominal wall via
in the 1990s [1]. IPOM is still the mainstay of the a small transhernial incision [5].
repair of ventral hernia, but it has not been with-
out limitation. Adhesive bowel obstruction, mesh
erosion, enterocutaneous fistula, and chronic pain Indications
are due to tight mesh fixations [2]. Extraperitoneal
mesh placement offer advantages: the retromus- Ventral hernias (primary, incisional, and also com-
cular positioning of the mesh permits the integra- plex ventral hernias—multiple sites hernias)
tion of both sides, providing the repair with
superior tensile strength and costly coated mesh is
unnecessary. Nevertheless, the laparoscopic Contraindications
extraperitoneal approach continues to pose limita-
tion in available degree of freedom and significant • Mesh infection and/or fistula
ergonomic challenge to the operating surgeons. • Loss of domain
To overcome these technical difficulties, two • Dystrophic or ulcerated skin (relative)
approaches were developed, the enhanced-view • Incarcerated (relative)
totally extraperitoneal (eTEP) technique and the • Previous retromuscular ventral hernia repair
mini or less open sublay (MILOS) repair. eTEP (relative)
has initial approach for the inguinal hernia repair • Previous incision from xiphoid process to the
[3], but combined with other retromuscular and pubic bone (relative)
preperitoneal repair of ventral hernia repairs such
as Rives-Stoppa or Transversus Abdominis
Release (TAR), it enables us to put the mesh pre- Preoperative Assessment
peritoneal space and restore the midline defect
• Detailed history (review of prior medical and
surgical records of previous interventions,
K. Imamura (*)
Minimally Invasive Surgery Center, anatomy, and the presence of any mesh or
Yotsuya Medical Cube, Tokyo, Japan fixation devices)
e-mail: k-imamura@mcube.jp • Physical examination
V. G. Radu • Biochemical studies to assess their baseline
Medlife, Bucharest, Romania health
https://doi.org/10.1007/978-981-19-3755-2_60
428 K. Imamura and V. G. Radu
• Energy device (optional)

• Trocars size and position (see below)
Surgical Technique
1. Development of the retrorectus space and port

placement
• General rule for the port placement:

Trocars to be placed at the opposite part of
the abdomen from the location of the her-
nia defect (Fig. 2).
–– Lower midline defects: cranial approach
(Fig. 2 top left).
–– Upper midline defects: caudal approach
Fig. 1 3D reconstructed CT images are useful to know (Fig. 2 top right).
the relationship between the location of the hernia orifice –– Lateral defects: contralateral lateral
and anatomy of the abdominal muscle wall
approach (Fig. 2 bottom).
• Dissecting the retrorectus space using a
• Defect location and size: up-to-date computed balloon trocar or an optic trocar (Fig. 3).
tomography (CT) study of abdomen and pel-
vis is recommended (Fig. 1) Caution: To avoid pneumoperitoneum, tro-
• Prior or current wound complication car should be held horizontally along the ante-
• Presence of ostomy rior layer of the posterior sheath. Figure 4
• Excess skin indicates the tip of the optic trocar mistakenly
• Screening colonoscopy for patients over the breaks the posterior sheath.
age of 50 years (optional) Caution: When using a balloon dissector, it
is critical to avoid overinflation which may
rupture the linea semilunaris and conse-
Enhanced-View Totally quently injure the neuromuscular bundles
Extraperitoneal (eTEP) Technique passing through posterior sheath to the rectus
muscle.
OT Setup and Patient’s Position • The retromuscular space is insufflated with
CO2 to a pressure of 10–15 mmHg (Fig. 5).
• Supine position with arms tacked by the side; 2. Crossover of the midline
the table is flexed, putting the patient in
hyperextension • “Crossover” refers to the surgical dissec-
• After induction of general anesthesia and intu- tion that joins one retrorectus space to its
bation, a Foley catheter is routinely placed contralateral counterpart without violating
• Instrumentation required: 0 or 30° telescope the intra-abdominal cavity.
10 mm • Accomplished by remaining superficial to
• 30° telescope 5 mm the falciform or umbilical ligaments—
• Atraumatic Graspers [2] 5 mm depending on where the crossing-over of
• Curved Scissors [1] 5 mm linea alba is performed (Fig. 6).
• Suction/irrigation device • Crossover should ideally be performed at a
• Needle driver level of the midline which has not been
• Hook electrocautery previously violated.
Extraperitoneal Ventral Hernia Repair 429
Fig. 2 Ports placement and patient’s position in three dif- epigastric arteries were marked by using preoperative
ferent situations. Upper left: Cranial approach. Upper ultrasound. Bottom: Lateral approach for an incisional
right: Caudal approach for an epigastric hernia, inferior hernia located just cephalic of the right iliac crest
3. Connection of both retrorectus spaces, left 4. TAR (when needed)

and right
• Indication of TAR: additional TAR may be
• Both retrorectus spaces are linked by the pre- necessary if maximal defect width closely
peritoneal bridge represented by the falciform approximates or exceeds 2× rectus width
ligament and/or umbilical ligament (Fig. 7). (Dr. Alfredo Carbonell-ninth Annual AWR
• The retrorectus dissection is limited later- Summit, Montana, Feb 2018), tension on
ally by the semilunaris lines, where neuro- the posterior layer, narrow unilateral retro-
vascular bundles pass through the posterior rectus space(<5 cm), poor compliant
sheath to the rectus muscles. abdominal wall.
Fig. 3 Dissecting the

retrorectus space using
an optic trocar
Fig. 4 Tip of the optic trocar entered the extraperitoneal

fat
Fig. 6 Crossing the midline anteriorly to the falciform
ligament
Fig. 5 Retrorectus dissection
Fig. 7 Connecting the both retrorectus spaces

Fig. 8 Hemi-TAR
• Incision of the posterior lamella of the inter-

nal oblique fascia 1 cm medially to the semi-
lunaris line to protect the neurovascular
bundles (the last 6 pairs of intercostal nerves).
• “Bottom to top” or “top to bottom” depend-
ing on comfort of the surgeon.
• Transection of transversus abdominis mus-
cle (TA) and posterior component separa-
tion should be done as laterally as possible,
to the psoas muscle, and as cranial (behind Fig. 9 Closure of anterior sheath by nonabsorbable
the diaphragm) as it is needed, depending suture
on hernia location.
5. Closure of the posterior fascial layer defect 6. Closure of the anterior fascia (Restoration of
linea alba)
• Closure of the posterior layer is necessary
to keep a barrier between the mesh and • Restoration of the linea alba is done by
viscera. suturing the anterior rectus sheaths on the
• This posterior layer is not a layer of resis- midline. Nonabsorbable barbed 0 (zero)
tance, so it is recommended to preserve the sutures in running fashion (Fig. 9)
peritoneum (the falciform ligament) as a • When we pull the stitch, reduce the pres-
bridge between the rectus sheaths. sure of insufflation to 5–6 mmHg
• It is strongly recommended to avoid any
tension in the suture line on the posterior 7. Mesh placement
layer. To reduce tension between the poste-
rior sheath, hemi-TAR (unilateral) or TAR • Appropriate mesh size selection: entire
could be necessary (Fig. 8). dissected area should be covered
• Medium weight macroporous mesh (poly-
Compared with the anterior hernia orifice, propylene or polyester) (Fig. 10)
the gap between the posterior layers became • Deployed through 12 mm trocar
larger. In this case, right hemi-TAR was useful • Mesh fixation is not necessary, except in
to close the posterior layer without tension. the situation of suprapubic defect.
• Needle driver
• Hook electrocautery
Surgical Technique
1. Small incision directory above the center of

the hernia defect (Fig. 11)
• skin incision of 2–5 cm = mini-open,
6–12 cm = less-open
2. Hernia sac preparation (Fig. 12)
Fig. 10 Mesh placement
3. Small incision of the peritoneum for diag-
nostic laparoscopy (Fig. 13)
8. Drain placement (optional) 4. Resection of abundant peritoneum of the her-
9. Exsufflation nia sac (Fig. 14)
• Slow exsufflation under direct vision to
ensure the mesh remains in the correct
position.
ini or less Open Sublay (MILOS)

M
Repair
MILOS is a minimally invasive transhernial

approach. It is an open procedure, using endo-
scopic dissection instruments. eMILOS is an
endoscopic MILOS variation and divided into
single-port and multiple port. Fig. 11 Skin incision (4 cm) over the hernia sack.
(Courtesy of Dr. Taketo Matsubara at St. Luke’s
International Hospital, Tokyo, Japan)
OT Setup and Patient’s Position
Supine position with arms tacked by the side or

in lithotomy position
Instrumentation required
• Standard laparoscopic instruments
• 30° telescope 10 mm
• Atraumatic Graspers (2) 5 mm
• Curved Scissors (1) 5 mm
• Rectangular retractors
• Light-armed laparoscopic instruments:
EndoTorch ™ (Wolf TM, Knittlingen,
Germany) (optional)
• Flexible single ports (optional) Fig. 12 Dissection of the hernia sac and clear exposition
of the hernia ring. (Courtesy of Dr. Taketo Matsubara at
• Suction/irrigation device St. Luke’s International Hospital, Tokyo, Japan)
Fig. 13 Dissection of the hernia sac and clear exposition

of the hernia ring. (Courtesy of Dr. Taketo Matsubara at
St. Luke’s International Hospital, Tokyo, Japan) Fig. 15 Resection of abundant peritoneum of the hernia
sac. (Courtesy of Dr. Taketo Matsubara at St. Luke’s
International Hospital, Tokyo, Japan)
Fig. 14 Transhernial laparoscopy. (Courtesy of Dr. Fig. 16 Closure of peritoneum. (Courtesy of Dr. Taketo
Taketo Matsubara at St. Luke’s International Hospital, Matsubara at St. Luke’s International Hospital, Tokyo,
Tokyo, Japan) Japan)
5. Complete and precise exposure of the fascial • With large ventral hernias, MILOS and
edge of the hernia orifice eMILOS operation can be combined with
6. Transhernial extraperitoneal dissection TAR.
around the hernia gap 7. Closure of the abdominal cavity (Figs. 16
and 17)
• Rectangular retractors are used to lift the 8. Transhernial extraperitoneal mesh
abdominal wall. implantation
• EndoTorch™ (laparoscopic instruments • The mesh should posteriorly overlap the
armed with a light tube) is a specially hernia defect by at least 5 cm (Fig. 18).
designed instrument for this dissection 9. Mesh fixation (optional)
(optional). 10. Hernia defect closure (Fig. 19)
• It is important to clearly expose the poste-
rior sheath to enable safe opening of the
retromuscular space (Fig. 15).
• Injury to the bowel

• Hematoma
• Recurrence
• Intraparietal hernia: Dehiscence of the pos-
terior sheath closure results in an intrapari-
etal hernia in which the viscera may become
incarcerated between mesh anteriorly and
the posterior sheath (Fig. 20). To avoid any
tension on the suture line, change the direc-
tion of suturing to close the posterior
fascia.
Fig. 17 Closure of posterior rectus sheath. (Courtesy of

Dr. Taketo Matsubara at St. Luke’s International Hospital,
Tokyo, Japan)
Fig. 18 Mesh with at least 5 cm overlap. (Courtesy of Dr.

Taketo Matsubara at St. Luke’s International Hospital,
Tokyo, Japan)
Fig. 19 Anterior rectus sheath closure. (Courtesy of Dr.

Taketo Matsubara at St. Luke’s International Hospital,
Tokyo, Japan)
Fig. 20 Intraparietal hernia developed 19 days after the index operation. Treated by using IPOM
Postoperative Care 2. Robinson TN, et al. Major mesh-related complications

following hernia repair. Surg Endosc Other Interv
Tech. 2005;19:1556–60.
• Standard Analgesia 3. Daes J. The enhanced view-totally extraperitoneal
• Discharge the patient when the patient is able technique for repair of inguinal hernia. Surg Endosc.
to ambulate 2012;26:1187–9.
4. Belyansky I, et al. A novel approach using the
• Reduce sports activities and carrying heavy enhanced-view totally extraperitoneal (eTEP) tech-
weight for 2 weeks nique for laparoscopic retromuscular hernia repair.
Surg Endosc. 2018;32:1525–32.
5. Reinpold W, et al. Mini-or less-open sublay operation
(MILOS): a new minimally invasive technique for the
extraperitoneal mesh repair of incisional hernias. Ann
References Surg. 2019;269:748–55.
1. LeBlanc KA, et al. Laparoscopic repair of incisional

abdominal hernias using expanded polytetrafluoroeth-
ylene: preliminary findings. Surg Laparosc Endosc.
1993;3:39–41.
Endoscopic Anterior Component
Separation Technique (eACS)
Component separation technique (CST) provides Contraindications

a substantial amount of medial advancement of
myofascial components of the abdominal wall • Noncompliant abdominal wall from previous
and is useful in addressing large and complex repair/mesh
hernia defects during open ventral hernia repair. • Concomitant TAR
Classic anterior CST is associated with high • Defects are disproportionally wider than lon-
rates of surgical site occurrences and infection ger (relative)
[1]. To reduce wound complications, endoscopic
approach was developed [2]. Although endo-
scopic anterior CS (eACS) has lost popularity Preoperative Assessment
due to recent trend toward TAR for complex
abdominal wall reconstruction cases [3], eACS • Same as previous chapter: “extraperitoneal
result in a similar wound morbidity and recur- ventral hernia repair.”
rence rate as TAR [4]. eACS could be another
option in the armamentarium to deal with com-
plex ventral hernias. OT Setup and Patient’s Position
• Supine position with both arms tacked in

Indications alongside the trunk of the patient.
• Using ultrasound imaging, semilunar line lat-
• Large ventral hernias (primary, incisional) eral to the rectus abdominis muscle is identi-
• To close the abdominal wall primarily without fied and marked on the skin bilaterally.
mesh in contaminated fields.
• *Caution! CST without mesh reinforcement Instrumentation Required

has high rates of hernia recurrence [5].
• 0° telescope 10 mm
K. Imamura (*) • 30° telescope 5 mm
Minimally Invasive Surgery Center, • A cylindrical dissection balloon dissector—
Yotsuya Medical Cube, Tokyo, Japan Spacemaker™ Pro Blunt Tip Trocar
e-mail: k-imamura@mcube.jp (Medtronic, New Haven, CT)
V. G. Radu • Atraumatic Graspers ( 2) 5 mm
Medlife, Bucharest, Romania

https://doi.org/10.1007/978-981-19-3755-2_61
• Curved Scissors ( 1)] 5 mm Case of eACS for Large Midline

A
• Suction/irrigation device Defect (Width 10 cm × Length
• Hook electrocautery 21 cm): eACS First, Inguinal
and Subfascial Approach
Surgical Technique 1. Identify and mark the bilateral semilunar line

(Fig. 2) under ultrasound guidance.
Three options should be considered. 2. Create the lateral endoscopic pockets.
• 12 mm incision is made in the lower quad-
1. eACS first or median laparotomy first? rant of the abdomen, lateral to the semilu-
• Some surgeons prefer to do eACS first to nar line (Fig. 3)
avoid contamination of lateral abdominal • Balloon dissector is introduced and
space from the midline wound [3] but oth- advances below the aponeurosis of exter-
ers perform median laparotomy first to
titrate the need for eACS [6]. The latter
avoids overtreatment, for hernia width can-
not be the only determinant; patient’s
height, visceral fat amount, and abdominal
wall compliance should be considered.
2. Depending on the place where the first port is
placed; precostal [6] or inguinal approach [7].
• Precostal approach: 13–15 cm away from
the xiphoid depending on the patient’s
height, and 4 cm above the costal arch.
• Inguinal approach (Fig. 1): lower lateral
quadrant of the abdomen, lateral to the pre-
viously marked semilunar line.
3. Depending on the location of the “endoscopic
pocket”; subfascial [6] and subcutaneous [3]
approach.
Fig. 2 Bilateral semilunar line is identified and marked
Fig. 3 As in a standard inguinal hernia repair, the exter-

nal oblique aponeurosis is incised and the space between
Fig. 1 Inguinal approach of eACS external and internal oblique muscle was identified
Endoscopic Anterior Component Separation Technique (eACS) 439
nal oblique muscle then the balloon is 4. Adhesiolysis and restoration of the linea alba
inflated (Fig. 4). (Fig. 8). the linea alba is reconstructed using
• The space is insufflated with CO2 and main- continuous endo-laparoscopic intracorporeal
tained at a pressure of 10 mmHg (Fig. 5). suturing
3. Transection of the external oblique muscle 5. Upon the restoration of the linea alba, a
(Fig. 6). synthetic mesh is rolled and inserted in the
• Additional 5 mm port is introduced at a surgical space and apposed to reinforce the
position lateral and superior to the camera abdominal wall (Fig. 9)
port.
• The external oblique aponeurosis is incised Here, below is a CT scan reconstruction of
laterally to the right semilunar line. the abdominal wall before and after 1 year fol-
• The external oblique aponeurosis is incised low-up showing the excellent reconstruction
from inguinal ligament to 4–6 cm above and repair of the abdominal wall midline defect
the costal margin (Fig. 7). (Fig. 10).
Fig. 4 Left: the Balloon dilatation is inserted in the subfascial space; Right: schematic of the balloon dilation within the
lateral muscles
Fig. 5 Overview of the space between the right external

and internal oblique muscle after removal of the balloon
and gas insufflation Fig. 6 Incise the elevated external oblique aponeurosis
• Small bowel injury during adhesiolysis

• Mesh infection
• Seroma
• Recurrence
–– same as the previous chapter: “laparo-
scopic IPOM and IPOM+.”
• Lateral hernia
Fig. 7 Endoscopic view after release of external oblique –– resulting from full-thickness injury to the
muscle linea semilunaris,
–– repair using TAR [8].
Fig. 8 The extracorporeal interrupted suture technique is Fig. 9 IPOM reinforcement

used to close the fascial defect
Peroperativ 3D-CT 1 year postop 3D-CT
Fig. 10 Left: preoperative 3D-CT image, yellow circle means hernia orifice. Right: 1-year postoperative 3D-CT image
Endoscopic Anterior Component Separation Technique (eACS) 441
Postoperative Care 4. Bittner R, et al. Update guidelines for laparoscopic

treatment of ventral and incisional abdominal wall
hernias (International Endohernia Society (IEHS)):
• Standard Analgesia part B. Surg Endosc. 2019;33:3511–49.
• Discharge the patient when the patient is able 5. Liang MK, et al. Ventral hernia management: expert
to ambulate consensus guided by systematic review. Ann Surg.
2017;265:80–9.
• Reduce sports activities and carrying heavy 6. Köhler G, et al. Evolution of endoscopic anterior com-
weight for 2 weeks ponent separation to a precostal access with a new
cylindrical balloon trocar. J Laparoendosc Adv Sug
Tech A. 2017;28:730–5.
7. Clarke JM. Incisional hernia repair by fascial compo-
nent separation: results in 128 cases and evolution of
References technique. Am J Surg. 2010;200:2–8.
8. Pauli EM, et al. Posterior component separation with
1. Ramirez OZ, et al. “Components separation” method transversus abdominis release successfully addresses
for closure of abdominal-wall defects: an anatomic and recurrent ventral hernias following anterior compo-
clinical study. Plast Reconstr Surg. 1990;86:519–26. nent separation. Hernia. 2015;19:285–91.
2. Rosen MJ, et al. Laparoscopic versus open-compo-
nent separation: a comparative analysis in a porcine
model. Am J Surg. 2007;194:385–9.
3. Daes J, et al. Endoscopic subcutaneous component
separation as an adjunct to abdominal wall reconstruc-
tion. Surg Endosc. 2017;31:872–6.
Role of Botulinum Toxin-A
in Chemical Component
Separation Technique
Sajid Malik and Davide Lomanto
Introduction cholinergic nerve endings [5]. This technique was

first reported by Ibarra-Hurtado et al. in 2009,
Ventral incisional hernia is one of the most com- where he used BTA to facilitate fascial closure in
mon log-term surgical complications after open 12 patients [6]. Lateral muscle paralysis was suc-
midline surgeries and accounts for almost cessfully achieved for tension-free hernia defect
20–30% of the cases [1, 2]. Repair of this inci- closure. BTA gives an additional advantage of
sional hernia is always challenging for general narcotic analgesia with due action blocking the
surgeons, especially for complex abdominal wall acetylcholine and also by preventing the release
hernia (CAWH) which also have a major physi- of substance P from presynaptic motor nerve end-
cal, social, and mental repercussions on patients ings [7]. Although BTA is a dangerous chemical,
[3]. Ramirez et al. devised a component separa- small well-calculated doses at specific points on
tion technique (CST) which aims medicalization abdominal wall, and also by avoiding vital mus-
of rectus abdominis muscles by complete divi- cles and viscera have good safety profile [7, 8].
sion of bilateral external oblique aponeurosis [4].
CAWH is the one with large hernia defects
with size >10 cm; re-recurrence; loss-of-domain; Botulinum Toxin
large abdominal wall/soft tissue defect and or
enterocutaneous fistula; hernias in anatomically ypes, Mechanism, Effects,
T
peripheral locations; and close-to-bone or local and Duration of Action
recurrent infection [4].
Recently, Surgeon’s technological armamen- Commercially available brands of BTA are
tarium has been widened for CAWH with intro- Botox® (Fig. 1) and Dysport®. This protein blocks
duction of preoperative injection of botulinum the release of acetylcholine in nerve terminals
toxin A (BTA). It is a protein with neurotoxin and paralyzes the muscles.
activity and is produced by Clostridium botuli- BTA is injected into ventral abdominal wall
num and has an inhibitory effect on presynaptic muscles to achieve functional denervation with
paralyzing effect that starts in 3–4 days and
reaches maximum effect in 2 weeks [8]. This
S. Malik (*)
flaccid paralysis of muscles leads to an increase
Department of Surgery, Allama Iqbal Medical
College, Jinnah Hospital Lahore, Lahore, Pakistan in abdominal cavity volume. This helps abdomi-
nal wall reconstruction without tension. Working
D. Lomanto
Department of Surgery, YLL School of Medicine, in close collaboration with interventional radiol-
National University Singapore, Singapore, Singapore ogists provides very promising results.

https://doi.org/10.1007/978-981-19-3755-2_62
444 S. Malik and D. Lomanto
Injections and Interventional

Radiological Kit
Author recommends six injections of 50 IU

Botox® (Botulinum Toxin A), Sterile water for
dilution, and six sets of 25G spinal needles.
Ultrasound kit should include minimum of linear
transducer (4–12 MHz) in sterile housing;
chlorhexidine can additionally be used as a cou-
pling agent (Fig. 2).
Selection of Site
The site of BTA is crucial and needs to be defined

very accurately. Elstner, Ibarra-Hurtado,
Zielinski, and Zandejas have described four dif-
ferent techniques but with one end result. They
Fig. 1 One of the commercially available brand in concluded that BTA administration between mid-
author’s own practice clavicular and midaxillary line pattern could be
of a straight line or triangular from costal margin
to superior iliac fossa [6, 10, 11]. According to
Practical Applications Ibarra-Hurtado technique, patient is placed in left
or right lateral position and five sites are identi-
Selection of Patient fied. Two on midaxillary line at equal distance,
three more on anterior axillary and midclavicular
Initially, we have to make certain selection crite- lines, and reciprocal is produced for other side as
ria on the basis of which we can provide benefits well. These techniques give advantage of
to the patients. There is no consensus but little increased length and decreased thickness of lat-
evidence on certain criteria which are published eral ventral abdominal muscles (Fig. 3).
in the literature, the most important of which is
the complex abdominal wall hernia repair
(CAWR) according to the size and site. The aver- onsenting, Selection of Dose,
C
age length of frontal abdominal musculature and Procedure
from the linea alba to midaxillary line is about
15–20 cm; and the length gained by BTA admin- Standard precautions for any interventional
istration is 3–4 cm on each side; and 6–8 cm in radiological procedure should be practiced as per
total. This suggests that a defect of 6–8 cm size national guidelines. Counseling and consenting
would likely get benefit from the best results regarding steps, and risks vs benefits should be
without component separation technique and the explained in a surgical clinical visit by the sur-
repair would be tension free as well [9]. The geon first and later by interventional radiologists.
author has performed a limited number of cases Back ache once paralyzing effects of toxin on
and more randomized trials are needed to estab- muscles should be addressed and abdominal
lish the facts. binder therefore should be prescribed before-
Role of Botulinum Toxin-A in Chemical Component Separation Technique 445
Fig. 2 Equipment required in procedure room under ultrasound guidance
Fig. 3 Various sites of injections and positioning of probe and needle

446 S. Malik and D. Lomanto
hand. Always explain to patient that respiration Aftermath

may be labored especially if undertaking heavy
activity. The author’s routine is to request interventional
During the procedure, inform the patient that radiologist, master in this technique and familiar
injections would be at various sites and not to with the results and outcome, of his hospital to
cough or take any sudden deep breath during the perform the BTA injection to the bilateral ante-
procedure to avoid any injury to underlying struc- rior abdominal wall muscles (external oblique,
tures. Identify three muscles [External Oblique internal oblique, and transversus abdominis)
Muscle (Ex Ob M.); Internal Oblique Muscle (In. 3 weeks before the operation. Ideal time for sur-
Ob M.); and Transversus Abdominus (Tr. Ab M.) gery is in third or fourth week after injections.
(Figs. 3 and 4)]. Either laparoscopic (preferably) or lap-assisted
There is a great personal bias in the selection surgery is performed when BTA provides its peak
of dose for BTA. Doses are varying in different effect at 4 weeks resulting in flaccid paralysis,
studies but all are aiming to decide “good effec- and then declined gradually in the next
tive” amount with “best” dilution at “appropri- 3–4 months. During this whole time, the patient
ate” time at “the best” site. Some believe a larger is advised to wear an abdominal binder to avoid
amount (400 IU) of BTA is safe but the author complications which might be a result of this
suggests 150 IU on each side with a total and flaccid muscle paralysis.
maximum amount of 300 IU (six injections total
as mentioned above).
Recently, we have proposed even a more con- Complications
servative approach to reduce the dosing amount to
100 IU on each side to a total of 200 IU for up to A study by Nielsen et al. reported one patient
10 cm defect. Equal amount of six doses at six sites who had pain related to BTA injections which
(three on each side) should be administered under was managed by narcotic pain medications and
ultrasound guidance by an expert hand to avoid resolved prior to surgery [13].
complications [9, 10]. Although the surgeons are Three more studies [11, 14, 15] reported
also expert in doing this procedure; radiologists are patients reporting with weak cough or sneeze
more helpful to perform this procedure [12]. after BTA injections but their condition improved
after wearing an abdominal binder [14]. In addi-
tion to this weak coughing, few patients reported
with a sense of bloating that resolved after hernia
repair while some others reported with backache
and dyspnea which improved with abdominal
Ex. Ob M. binder [15]. Based on these complications, the
In. Ob M. author devised a way to reduce the amount from
300 IU to 200 IU with a rationale of sparing the
Tr. Ab M.
transverses abdominis muscle which may allow
to increase core stability and ultimately will
reduce the side effects.
Conclusion
Initial results have shown BTA as a very good

Fig. 4 Identify three muscles shown with black arrow
alternative to CST for CAWH with minor side
[External Oblique Muscle (Ex Ob M.); Internal Oblique
Muscle (In. Ob M.); and Transversus Abdominus (Tr. effects. Dual advantages of tension-free hernia
Ab M.)] repair and analgesic effect have raised the
Role of Botulinum Toxin-A in Chemical Component Separation Technique 447
interest of researchers. Additionally, flaccid 7. Jankovic J, Albanese A, Atassi MZ, Dolly JO, Hallet
M, Mayer NH. Botulinum toxin: therapeutic clinical
relaxation of abdominal muscles decreases the practice and science. Philadelphia: Saunders Elsevier;
intra-abdominal pressure thus improving venti- 2009. p. 512.
lation complications and ultimately reducing the 8. Dressler D. Clinical applications of botulinum toxin.
need for and duration of invasive ventilation sup- Curr Opin Microbiol. 2012;15:325–36. https://doi.
org/10.1016/j.mib.2012.05.012.
port. These advantages further facilitate the post- 9. Lien SC, Hu Y, Wollstein A, Franz MG, Patel SP,
operative healing process as well. All these Kuzon WM, Urbanchek MG. Contraction of abdomi-
discussions are from initial results and large ran- nal wall muscles influences size and occurrence of
domized control studies on the dosage, tech- incisional hernia. Surgery. 2015;158:278–88. https://
doi.org/10.1016/j.surg.2015.01.023.
niques, and timing of BTA would be needed to 10. Weissler JM, Lanni MA, Tecce MG, Carney MJ,
reach a consensus. Shubinets V, Fischer JP. Chemical component separa-
tion: a systematic review and meta-analysis of botuli-
num toxin for management of ventral hernia. J Plast
Surg Hand Surg. 2017;51:366–74. https://doi.org/10.1
References 080/2000656X.2017.1285783.
11. Elstner KE, Read JW, Rodriguez-Acevedo O, Ho-Shon
1. Jairam AP, Timmermans L, Eker HH, Pierik REGJM, K, Magnussen J, Ibrahim N. Preoperative progressive
van Klaveren D, et al. Prevention of incisional hernia pneumoperitoneum complementing chemical compo-
with prophylactic onlay and sublay mesh reinforce- nent relaxation in complex ventral hernia repair. Surg
ment versus primary suture only in midline laparoto- Endosc. 2017;31:1914–22. https://doi.org/10.1007/
mies (PRIMA): 2-year follow-up of a multicentre, s00464-016-5194-1.
double-blind, randomised controlled trial. Lancet. 12. Bueno-Lledó J, Torregrosa A, Ballester N, Carreño O,
2017;390:567–76. Carbonell F, Pastor PG, et al. Preoperative progres-
2. Bikhchandani J, Fitzgibbons RJ Jr. Repair of giant sive pneumoperitoneum and botulinum toxin type
ventral hernias. Adv Surg. 2013;47:1–27. A in patients with large incisional hernia. Hernia.
3. Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE, 2017;21:233–43.
van Doorn HC, et al. Small bites versus large bites for 13. Nielsen M, Bjerg J, Dorfelt A, Jørgensen LN, Jensen
closure of abdominal midline incisions (STITCH): a KK. Short-term safety of preoperative administration
double-blind, multicentre, randomised controlled trial. of botulinum toxin A for the treatment of large ventral
Lancet. 2015;386:1254–60. hernia with loss of domain. Hernia. 2020;24:295–9.
4. Ramirez OM, Ruas E, Dellon AL. “Components sepa- 14. Farooque F, Jacombs AS, Roussos E, Read JW,
ration” method for closure of abdominal-wall defects: Dardano AN, et al. Preoperative abdominal mus-
an anatomic and clinical study. Plast Reconstr Surg. cle elongation with botulinum toxin A for com-
1990;86:519–26. plex incisional ventral hernia repair. ANZ J Surg.
5. Jankovic J, Brin MF. Therapeutic uses of botulinum 2016;86:79–83.
toxin. N Engl J Med. 1991;324:1186–94. 15. Rodriguez-Acevedo O, Elstner KE, Jacombs ASW,
6. Ibarra-Hurtado TR, Nuño-Guzmán CM, Echeagaray- Read JW, Martins RT, et al. Preoperative botulinum
Herrera JE, Robles-Vélez E, De Jesús G-JJ. Use of toxin A enabling defect closure and laparoscopic
botulinum toxin type A before abdominal wall hernia repair of complex ventral hernia. Surg Endosc.
reconstruction. World J Surg. 2009;33:2553–6. 2018;32:831–9.
Endo-laparoscopic Repair
of Lateral Ventral Hernia
James Lee Wai Kit, Sajid Malik, Sujith Wijerathne,

and Davide Lomanto
Introduction also occur due to denervation of the muscles as a

result of previous spine surgery, lobectomy inci-
Lateral ventral hernia (LVH) repair is a challeng- sion, injury, or rupture of the muscles due to blunt
ing procedure for surgeons because of the diffi- trauma [9]. The abdominal wall musculature is
cult anatomy, the difficult location, the little innervated in segments by the T7–T12 spinal
knowledge on treatment as compared to midline roots and any disturbance to these nerves can
defects, and the scarcity of cases and experience. lead to a weakening of the lateral wall muscles
Till now the poor outcomes including the poten- resulting in bulges or hernias [10].
tial risks of postoperative pain, infection, and Most surgeons opt for open repair of these
higher risk of recurrence have compromised the hernias because of their familiarity with the
success of several approaches [1–5]. approach and its accompanying greater ease of
Briefly, as LVH is described as a primary or tissue manipulation [2]. Conversely, Minimally
secondary defect located at the subcostal, flank, Invasive Surgery (MIS) approaches in abdominal
iliac, or lumbar regions. According to the wall hernia repair have evolved significantly with
European Hernia Society (EHS) classification the advent of several reported techniques which
[6–8], these defects are classified from L1 to L4, include classical Intraperitoneal Onlay Mesh
respectively (Table 1). Different types of second- repair (IPOM) or IPOM with defect closure (IPOM
ary hernias include defect or wide laxity that can plus/IPOM+), extended Totally Extraperitoneal
(e-TEP) repair, endoscopic retro-muscular repair,
J. L. W. Kit and Transabdominal Preperitoneal (TAPP)
Minimally Invasive Surgery Centre, National approach. These described techniques combine
University Hospital, Singapore, Singapore
the advantages of retromuscular or preperitoneal
Department of Surgery, YLL School of Medicine, mesh placement with the well-known benefits of
MIS approaches [2, 11, 12].
S. Malik
Allama Iqbal Medical College, Jinnah Hospital, Recent guidelines acknowledge with Grade C
Lahore, Pakistan (Oxford Classification) the laparoscopic lateral
S. Wijerathne (*) · D. Lomanto ventral hernia mesh repair of LVHR. This
Minimally Invasive Surgery Centre, National approach seems to be associated with fewer sur-
University Hospital, Singapore, Singapore gical site infections but equal rates of hernia
General Surgery and Minimally Invasive Surgery, recurrence and chronic pain when compared to
System, Singapore, Singapore
open mesh repair, but in conclusion they recom-
mend both open and laparoscopic mesh repair
National University Singapore, Singapore, Singapore equally [2, 6, 13]. Outcomes of LVH repair are
https://doi.org/10.1007/978-981-19-3755-2_63
450 J. L. W. Kit et al.
Table 1 EHS classification of ventral hernia based on location [8]

Zones Region Description
L1 Subcostal Between the costal margin and a horizontal line 3 cm above the umbilicus
L2 Flank Lateral to the rectal sheath in the area 3 cm above and below the umbilicus
L3 Iliac Between a horizontal line 3 cm below the umbilicus and the inguinal region
L4 Lumbar Latero-dorsal of the anterior axillary line
affected by both, patient factors and operative Patients with symptomatic but uncomplicated
technique and especially by the large size of her- lateral ventral hernias should undergo surgical
nia defects [11–14]. The complexity of the surgi- repair barring the absence of contraindications.
cal approach, with its limited dissection plane, Absolute contraindications to elective repair
the limitations placed on the overlapping of the include severe comorbidities unsuitable for gen-
prosthesis by structures like the iliac crest, ribs, eral anesthesia, uncontrollable coagulopathy,
and spine, combined with the lack of proper fixa- giant hernia with major loss of domain, major
tion makes this repair vulnerable to higher rates abdominal sepsis, giant hernia with loss of
of surgical complications and hernia recurrence. abdominal domain as well as poor quality of life
Thus, a successful repair of LVH repair neces- that would preclude meaningful outcome post-
sitates careful patient optimization, a thorough surgical repair.
understanding of the anatomy of the hernia Relative contraindications that are modifiable
including its size, location, and etiology, together prior to surgery include smoking, obesity, and
with a tailored surgical approach to ensure opti- diabetic control. Smoking increases the risk of
mal outcomes [2, 12, 15]. surgical site infection and should ideally be
This chapter aims to provide guidance on the stopped 6–8 weeks prior to elective ventral her-
management of these complex hernias. nia surgery. Obesity increases the risk of surgical
site infection, hernia recurrences as well as pro-
longs hospital stay post elective surgery. Patients
Indications prior to elective lateral ventral hernia repair
should aim for a BMI less than 30 kg/m2. Diabetic
Patients with asymptomatic ventral hernias can patients should also aim for adequate glucose
be considered for surgery. However, in patients control of Hba1c less than 8% prior to surgery.
who decline elective surgical intervention, they As with all surgical cases, patients should be
should be counseled on the risks of a watchful assessed prior to surgery for fitness for anesthe-
waiting approach with early recognition of symp- sia. Management of underlying comorbidities
toms of hernia complications. especially that of diabetes, smoking, and obesity
Patients with symptomatic ventral hernias are important as they pose risks to ventral hernia
should undergo surgical repair as the mainstay of repair.
treatment. Specific for lateral ventral hernias, it is impor-
Patients with hernia-related complications such tant that these patients undergo cross-sectional
as strangulation, obstruction, or incarceration preoperative imaging in order to delineate the
should aim to undergo early or emergent repair location of the defect and its contents. Evaluation
depending on their clinical condition. Concerns of the defect size is important as we recommend
during the repair for such hernias include the risk of the use of Botox injections for defects larger than
a contaminated field from bowel perforation or the 8 cm 4–6 weeks prior to surgery to increase
necessity of bowel resection, which may affect the abdominal domain to assist with the surgical
decision for mesh versus tissue repair in such cases. repair process.
Endo-laparoscopic Repair of Lateral Ventral Hernia 451
OT Setup Patient positioning is supine for most L1, L2,

and L3 cases with slight variations. L1, L2, and L3
• Please refer to OT setup chapter for laparo- cases required tiling the table with the hernia side
scopic hernia repair up towards the surgeon. L1 cases require a further
• Mesh preparation preoperatively is important reverse Trendelenburg positioning of about
to ensure all necessary equipment are on site 15–30°. L3 cases require a further Trendelenburg
and sized appropriately for the defect position of 15–30°. L4 cases being lateral require
• The choice of operative technique (Open vs a lateral decubitus (Figs. 1 and 2) with the hernia
Lap vs Robotic) should be individualized to side tilted away from the surgeon.
the patient Diagnostic laparoscopy should be per-
formed after gaining access to the peritoneal
cavity for IPOM+, TAPP, and TAPE cases.
Surgical Technique Adhesiolysis should be carefully performed if
We advocate a tailored MIS approach for patients

undergoing repair of lateral ventral hernias.
All patients undergoing surgical repair with
MIS approaches should be done under general
anesthesia. The repair techniques available are as
follows:
Repair Techniques
• Laparoscopic Intraperitoneal Onlay Mesh
Repair Plus (IPOM+)
• Laparoscopic/Robotic Transabdominal
Preperitoneal Repair (TAPP/rTAPP)
• Extended Totally Extraperitoneal Repair
(e-TEP)
Fig. 1 Performing robotic TAPP (rTAPP) in lateral decu-
• Laparoscopic Transabdominal Partial bitus position for a hernia in L4 region that resulted after
Extraperitoneal Repair (TAPE) bone harvesting from the iliac crest
The repair of lateral ventral hernias via the

MIS approach can be divided into the following
categorical steps:
General Steps
• Positioning
• Diagnostic Laparoscopy (except in e-TEP)
• Adhesiolysis (as required)
• Closure of fascia defect
• Mesh placement with at least 5 cm overlap
from original defect size
Fig. 2 Performing robotic TAPP in lateral decubitus
• Tacking of mesh with double-crown fixation position for a hernia in L4 region that resulted from likely
technique traumatic rupture of muscle
required for incisional hernia cases to clearly

delineate the fascia defect as well as ensure
adequate exposure for mesh placement.
Closure or approximation of defect followed
by mesh placement is thereafter performed for
all cases of lateral ventral hernia repair via the
MIS technique.
Choice of mesh is determined by the loca-
tion of the mesh placement, surgical technique
utilized as well as the presence of contamina-
tion during the surgery process. In extraperito-
neal mesh placement like TAPP (lap or robotic)
and e-TEP, standard macroporous polypropyl-
ene or polyester meshes are utilized; in some Fig. 3 Planned port placement for laparoscopic IPOM+
repair of an incisional hernia in L1 region
cases, self-gripping meshes may be useful to
avoid challenges in mesh placement and fixa-
tion. Composite meshes are used for IPOM+ and TAPP/rTAPP Approach
TAPE approaches. A minimum 5 cm overlap of
the original defect prior to closure is required. Both endo-laparoscopic or robotic technique can be
For lateral hernia closer to bone structures like used for the TAPP approach and they are similar in
the iliac crest, mesh should be fixed to it using technique. Access is like the IPOM+ technique with
permanent metal tackers while absorbable tack- care to ensure adequate space between the ports and
ers can be used for fixation to soft tissue in a clas- defect to allow room for creation of the peritoneal
sical “double-crown” technique. flap. Surgeons should be mindful that more space is
needed for bigger defects. The peritoneal flap
should be created at least 8 cm away from the edge
IPOM+ Approach of the defect and for defects larger than 3–4 cm, this
distance should be revised to be greater than 8 cm.
We recommend a standard IPOM technique for This is to ensure sufficient ergonomics for operat-
the IPOM+ approach with the addition of closing, mesh placement, and closure of the peritoneal
ing the fascia defect using either transfacial flap. For the robotic approach, we recommend an
nonabsorbable sutures or intra-corporeal non- additional 10–12 mm port to facilitate insertion and
absorbable barbed sutures or both. Access is removal of sutures as well as for suctioning where
done using a 10–12 mm port on the contralat- required. We recommend laparoscopic TAPP for L2
eral abdominal wall to the hernia away from cases with defects no larger than 4–5 cm and robotic
the defect with adequate space for mesh over- TAPP for cases with larger defects, especially in the
lap after defect closure. Two 5 mm working L4 region where ergonomics of laparoscopic repair
ports should be placed on either side of the are not favorable, especially during laparoscopic
10–12 mm port about 6–8 cm away. A compos- closure of the defect requiring plication.
ite mesh posterior to the peritoneum should be
placed in an underlay position. IPOM+
approach should be considered in cases where e-TEP Approach
intra-abdominal adhesions are expected and
where peritoneum damage secondary to adhe- Access for the e-TEP approach (see Chapter on
siolysis is expected. We also recommend this e-TEP) is like groin hernias with the 10–12 mm
technique for L1 hernias (Fig. 3) at the subcos- port placed through an infraumbilical incision
tal region where extraperitoneal dissection medial to the semilunar line on the opposite side
beyond the costal margin can be technically of the hernia after entering the preperitoneal ret-
challenging. rorectus plane. The plane should subsequently be
developed using the camera as well as insuffla- TAPE Approach

tion of gas through the port to aid dissection. Two
5 mm working ports can thereafter be placed Access and port placement for the Transabdominal
inferior to the camera port after creating adequate Partial Extraperitoneal approach (TAPE) is similar
space at the space of Bogros and Retzius (Fig. 4). to the TAPP technique. We recommend a dissec-
We recommend the e-TEP approach for primary tion of the peritoneal flap-like TAPP for groin her-
hernias in the L2 region for defects no larger than nias to be undertaken until the clear identification
4–5 cm in size. This technique is also applicable of the pectineal ligament of Cooper and the land-
for selected hernias in L3 region. mark myopectineal structures is performed. A
composite mesh is used in the TAPE technique as
part of the mesh will be exposed beyond the free
edge of the peritoneal flap. We recommend this
technique in cases where the peritoneal coverage of
the defect and mesh is not adequate due to prior
extensive adhesiolysis. After placement of the
mesh, the free edges of the remaining peritoneum
should be tacked over the mesh and abdominal wall
using absorbable tackers. This approach is mostly
utilized for midline and lateral flank hernia.
Suggested Diagram for a Tailored Endo-
Laparoscopic Lateral Ventral Hernias Repair
(Fig. 5).
In a nutshell, lateral ventral hernia which is
Fig. 4 Port placement for e-TEP repair of a Spigelian actually a quite challenging condition can be
hernia
Fig. 5 Tailored
MIS Approach for LVH
approach for lateral
ventral hernia
BMI > 30kgm2 Defect size 8 – 15 cm#
Pre-operative Weight
Pre-operative Botox
Management
L1 L2 L3 L4
IPOM+ Primary / TAPE Complex /

Non-complex TAPP Expertise Available
eTEP
Yes No Yes No
eTEP TAPP rTAPP^ TAPP

IPOM+
# Open approach should be considered for defects larger than 15cm

^ Robotic approach can be used to repair hernia in all 4 regions if expertise is available
Table 2 Summary of procedure techniques

IPOM+ TAPP e-TEP TAPE
Access 10–12 mm port 10–12 mm port opposite 10–12 mm port 10–12 mm port
opposite hernia with hernia with 2 × 5 mm opposite hernia with opposite hernia with
2 × 5 mm working working ports 2 × 5 mm working 2 × 5 mm working
ports approximately approximately 6–8 cm ports approximately ports approximately
6–8 cm away from away from the camera 6–8 cm inferior from 6–8 cm away from
the camera port port. Consider additional the camera port the camera port
10–12 mm port for
rTAPP
Mesh choice Composite mesh Synthetic mesh— Synthetic mesh— Composite mesh
Consider self-gripping Consider
self-gripping
Mesh Underlay Sublay Sublay Sublay/underlay
location
Useful Expected intra- Inadequate peritoneal
situations abdominal adhesions, coverage
near costal margin
Appropriate Large defects 4–5 cm defects 4–5 cm defects 4–5 cm defects
defect size
Hernia sites L1/L2 L2/L3/L4 L2/L3 L2/3/4
Flap entry N.A 8 cm from edge of defect 10–12 mm Portsite 8 cm from edge of
defect
managed by endo-laparoscopic method using Patients should be followed up in the clinic at

TAPP, TAPE, e-TEP, and rTAPP with each hav- routine intervals initially 2 weeks after surgery
ing individualized selection criteria (Table 2). and thereafter at the 1 month, 3 month, 6 month,
and 1 year mark.

Discussion
General postoperative complications apply to
lateral ventral hernia repairs as well such as Lateral ventral hernia is a challenging condition
mesh-related infections, seroma formation, and to treat. Our approach via an endo-laparoscopic
recurrence. method using TAPP, TAPE, e-TEP, and rTAPP
has also been described by other authors [16].
They also conclude that extraperitoneal or pre-
Post-Op Care peritoneal mesh placement allows adequate
abdominal wall reinforcement and reduces the
The use of prophylactic antibiotics is essentially need for extensive surgical fixation and related
in view of mesh implantation. There is no role for complications.
continuation of antibiotics postsurgery. Patients Authors such as Cavalli et al. [3] and
should receive a standardized analgesia package Katkhouda et al. [4] have also published their
for pain control. They should also be counseled approaches to lateral ventral hernia repair through
on the use of an abdominal binder, especially in an open method. Cavalli et al. describe a four-
the presence of large hernias. Return advice look- step technique with an open extraperitoneal
ing out for symptoms of fever, worsening abdom- approach for complex LVH in particular for large
inal pain, and erythema over the hernia site hernia size white Katkhouda et al. recommended
should be done routinely to both patients and an open technique with mesh fixation to bony
relatives. structures to reduce recurrences.
We advocate a tailored approach for lateral incisional abdominal wall hernias (international
Endohernia society (IEHS)): part B. Surg Endosc.
ventral hernias. No technique is superior to the 2019;33(10):3069–139. https://doi.org/10.1007/
other for MIS LVH repair and a tailored approach s00464-019-06908-6.
based on patient and hernia characteristics and 8. Muysoms FE, Miserez M, Berrevoet F, et al.
also taking the facilities and expertise in complex Classification of primary and incisional abdominal
wall hernias. Hernia. 2009;13(4):407–14. https://doi.
hernia techniques into consideration can provide org/10.1007/s10029-009-0518-x.
the best results and the value of open surgical 9. Dakwar E, Le TV, Baaj AA, et al. Abdominal wall
approach should not be taken lightly in a large paresis as a complication of minimally invasive lat-
and complex hernia. eral transpsoas interbody fusion. Neurosurg Focus.
2011;31(4):E18. https://doi.org/10.3171/2011.7.FO
CUS11164.
10. Pulikkottil BJ, Pezeshk RA, Daniali LN, Bailey
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8. https://doi.org/10.1007/s10029-020-02126-5. doi.org/10.1007/s00464-017-5840-2.
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6. Bittner R, Bain K, Bansal VK, et al. Update of R, Jeekel J. An evaluation of risk factors in inci-
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7. Bittner R, Bain K, Bansal VK, et al. Update of
guidelines for laparoscopic treatment of ventral and
Part XVIII
Diastasis Recti
Posterior Plication or Combined
Plication of the Recti Diastasis
Davide Lomanto, Raquel Maia, and Enrico Lauro
The anterior abdominal wall consists of the The survey revealed a broad range of widths,
abdominal rectus muscles separated by the linea and the data collection allowed the authors to
alba, which is the fusion of the aponeuroses of consider “normal” up to a width of 15 mm at the
external and internal oblique muscles and trans- xiphoid, up to 22 mm at the reference point 3 cm
versus abdominis. above the umbilicus, and up to 16 mm at the ref-
Rectus abdominis diastasis (RAD) is a clinical erence point 2 cm below the umbilicus [2].
condition where the inter-rectus distance is Mota et al. studied the IRD during and after
abnormally wide with a consequent bulging on pregnancy in primiparous women considering as
the midline, due to a weaker and thinner linea “normal” the measurements between the 20 and
alba (Fig. 1). 80th percentiles. During pregnancy, the IRD
Even though there is not an agreement about measured 49–79 mm at 2 cm below the umbili-
the average inter-rectus distance (IRD) to be con- cus, 54–86 mm at 2 cm above the umbilicus, and
sidered abnormal, many authors describe a sepa- 44–79 mm at 5 cm above the umbilicus, while in
ration wider than 2 cm as RAD [1]. the postpartum period 6 months after birth, the
The measurements may differ based on the IRD decreased to 9–21 mm, 17–28 mm, and
location along the linea alba above or below the 12–24 mm at 2 cm below, 2 cm above and 5 cm
umbilicus. above the umbilicus, respectively [3].
Beer et al. examined 150 nulliparous women The authors concluded that in primiparous
between 20 and 45 years of age by ultrasound at women, the IRD may be considered “normal” up
three reference points to evaluate the normal to values wider than in nulliparous.
IRD. As shown in an anatomical study by Rath
et al. the normal inter-rectus width is age-
related: below 45 years of age diastasis is con-
D. Lomanto (*) sidered as a separation of the two rectus muscles
Department of Surgery, Yong Loo Lin School of exceeding 10 mm above the umbilicus, 27 mm
Medicine, National University Singapore,
Singapore, Singapore at the umbilical ring, and 9 mm below the umbi-
e-mail: surdl@nus.edu.sg licus, while above 45 years of age these values
R. Maia increase up to 15 mm, 27 mm, and 14 mm,
Brazilian College of Gastric Surgeons, respectively [4].
Sao Paulo, Brazil
E. Lauro
General Surgery Division, St. Maria del Carmine
Hospital, Rovereto, Italy

https://doi.org/10.1007/978-981-19-3755-2_64
Fig. 1 Schematic of normal linea alba and Recti muscle diastasis
Risk Factors separation can increase, decrease, or stay the

same during the postpartum period [7, 8].
Rectus abdominis diastasis can be congenital or Exercise significantly reduced the risk of
acquired. developing RAD [9].
Several congenital anomalies are associated
either with defects of the anterior abdominal Obesity—Weight gain with an increase in the
wall, involving malformation of the somatic and intra-abdominal pressure can lead to a gradual
visceral layers (i.e., the Cantrell pentalogy or tho- rectus muscle separation [10].
racoabdominal syndrome, Beckwith-Wiedemann Collagen disease—As in patients with hernias or
syndrome, Opitz syndrome, midline defect syn- aortic aneurysm, patients with diastasis recti
drome, and prune belly syndrome), or with an present decreased levels of type I and III col-
autosomal dominant transmission as an abdomi- lagen [11, 12].
nal wall development failure [5, 6]. Aneurysm—Some, but not all studies, support
In the acquired RAD, the weakening and lax- such an association as a result of a collagen
ity of the abdominal wall tissues result in an tissue disorders [13].
abnormal inter-rectus distance and often in a typ-
ical abdominal protrusion.
The fascia can become thin due to stretching, Classification
which can be caused by an elevated intra-abdominal
pressure, such as in pregnant and obese patients, or Ranney proposed a classification of RAD based
due to prior abdominal surgery. An association of on the width of the IRD: width < 3 cm, between
RAD with other disorders affecting connective tis- 3 and 5 cm, or > 5 cm are classified as mild, mod-
sue suggests an underlying tissue weakness. erate, or severe, respectively [14].
Recently, the German Hernia Society and the
Risk factors for acquired RAD are: International Endo Hernia Society proposed a more
• Pregnancy—Pregnancy increases the risk of specific classification based on the diastasis length
developing RAD; however, not all pregnant and location (subxiphoidal M1, epigastric M2,
women develop diastasis. The amount of the umbilical M3, infraumbilical M4, and suprapubic
Posterior Plication or Combined Plication of the Recti Diastasis 461
Rectus Diastasis Classification
M1 subxiphoidal
subxyphoidal M1 3 cm M2 epigastric
Midline
M3 umbilical
epigastric M2
M4 infraumbilical
M5 suprapubic
3 cm
umbilical M3 Length: cm Width: cm
3 cm
Width W1 W2 W3
infraumbilical M4
cm < 3 cm 3- 5 cm > 5 cm
suprapubic M5 3 cm
Fig. 2 Classification of RAD based on length and width of the IRD
M5), diastasis width (W1 < 3 cm, W2 = 3 ≤ 5 cm, (umbilical, epigastric) or incisional hernias can
and W3 > 5 cm), concomitant hernias, previous coexist with RAD.
operations, number of pregnancies/births, skin lax-
ity, and pain assessment [15] (Fig. 2).
Diagnosis
Clinical Features The physical examination can detect a RAD as a

bulged linea alba by a head lift maneuver in most
Rectus abdominis diastasis may be symptomatic patients.
or asymptomatic. An abnormally wide abdomi- This protrusion normally extends from the
nal muscle distance results in a modification of xiphoid to the umbilicus and possibly more cau-
the inner abdominal pressure and can affect the dally to the pubis.
stability of the abdominal “box,” having an The width between the two rectus abdominis
impact on the vertebral column, the diaphragm, muscles can be easily taken at rest and during
and the pelvic floor. contraction at several levels along the linea alba
Symptoms include abdominal pain or discom- but, if a surgical treatment is required, an imaging
fort, lumbar back pain, and pelvic instability, investigation is mandatory.
with urogynecological symptoms, such as uri- Ventral and incisional hernias are obviously
nary incontinence, fecal incontinence, and pelvic associated with a fascial defect, while RAD does
organ prolapse. not present any fascial interruption.
In addition, patients affected by RAD often
report a lower acceptance of their body image
and a lower quality of life compared with the Imaging
general population.
Patients with acquired RAD typically are Ultrasound (US) is a useful noninvasive method
middle-aged and older men with central obesity, that can confirm diastasis and at the same time
or small, fit women with previous multiple or exclude other causes of bulging.
large fetus births. Measurements are usually taken at rest and
RAD does not consist of a proper abdominal during abdominal muscle activation (i.e., during
wall defect, and therefore there is no risk of a head lift maneuver) at different reference points
incarceration or strangulation, although ventral above and below the umbilicus.
Fig. 5 CT SCAN imaging showing RAD at the

Fig. 3 Ultrasound findings umbilicus
Indications and Management
RAD alone does not require surgical repair: con-

servative management with weight loss and exer-
cise are the suggested treatment [17–19].
In case of RAD associated with abdominal
hernias, rectus abdominis plication with mesh
reinforcement is recommended [19, 20].
Indications for mini-invasive (MIS) surgical
repair include the presence of a midline/umbili-
cal hernias, medium size RAD (measuring up to
Fig. 4 CT SCAN imaging showing RAD above the 5 cm, but no consensus reached in the current lit-
umbilicus
erature), no prior hernia repair or laparotomy
(relative contraindication), and no need for
US intersession reliability has been shoved to abdominoplasty. Repair of the RAD with con-
be high in the supraumbilical region, but poor comitant midline hernia is critical as may lead to
when measuring IRD below the umbilicus [16] a so-called pseudo-recurrence where the pres-
(Fig. 3). ence of a midline bulge may affect patient
Computed tomography (CT) without contrast satisfaction.
medium at rest and during Valsalva maneuver
offers an accurate investigation of the inter-rectus
distance and of the whole abdominal wall anat- Surgical Repair
omy, including the possible association with ven-
tral or incisional hernias. Different surgical approaches have been reported
In addition, CT Scan allows a useful three- from open to endo-laparoscopic or robotic.
dimensional reconstruction for better anatomical Similarly, several different techniques have been
preoperative assessment (Figs. 4 and 5). described for the RAD repair like anterior or pos-
Fig. 7 Large W3 Rectus Diastasis
utilized for the plication. The plication can be

completed by using a mesh for reinforcement.
If an anterior plication is performed, the mesh
can be placed either in onlay position or in the
retrorectus space (sublay). In case of laparo-
scopic posterior plication, the mesh is placed
Fig. 6 Intraoperative view of the abnormal inter-rectus intraperitoneal (IPOM). Absorbable or nonab-
distance in a patient with RAD sorbable can be utilized.
In this chapter, we will focus on the Combined
or Posterior plication of the RAD with mesh rein-
terior rectus sheath plications and mesh repair forcement. Our Indication for this technique is
(Fig. 6). ONLY for a RAD associated with primary mid-
If we classify the different techniques, we line hernia in which an only hernia repair may
have: lead to failure due to the lack of midline support.
In fact, in the long term, the hernia repair is going
For the MIS approaches: to fail if not treated concurrently with RAD [21,
• Laparoscopic with Intraperitoneal Onlay 22] (Fig. 7).
Mesh (IPOM) reinforcement Our technique is derived from the classical
• Endo-laparoscopic in which the mesh is posi- IPOM Plus in which the defect closure is added
tioned extraperitoneal sublay or onlay to the simple IPOM repair (see related Chapter).
• Robotic-assisted for all above
Plication
• Routine blood investigations
Suture plication of the anterior, posterior, or both • Bowel Preparation (optional)
rectus aponeurosis can be performed using a sin- • Antibiotic-prophylaxis
gle or double-layer suture technique or a triangu- • CT Scan (in selected cases: recurrent, incar-
lar “mattress” running suture technique. Slowly cerated, etc.)
absorbable or nonabsorbable 2–0 sutures can be • Weight Loss if BMI >30
–– V-Lock suture, nonabsorbable 0

Fig. 8 OR Setup for Ventral Hernia and RD Repair (Medtronic, USA)
–– Composite Mesh with anti-adhesive
barrier
T Setup, Patient’s Position
O –– Tackers; absorbable (for mesh fixation)
and Trocars Placement (Fig. 8) • Trocars size and position (Fig. 9)
–– 12 mm port inserted laterally between the
• Monitor position costal margin and the Anterior superior
–– Position of the monitor should be opposite iliac spine (ASIS)
to the Surgeon Operator. –– 5 mm ports (2) inserted on either side of the
• Patient Position and preparation optical trocar
–– Standard supine position with both arms –– An additional 5 mm port may be required
tucked at the side or on the arm board in an approachable position for the mesh
depending on the size and site of hernia fixation
(Fig. 3)
–– Surgeon and Assistant stand on the side of
the patient Surgical Technique
• Instrumentation required
–– Hasson or Optical Trocar or Veress Needle The hernia defect and RAD should be marked
–– Trocars: One 10–12 mm and two 5 mm preoperatively. Pneumoperitoneum can be estab-
–– Laparoscopic camera unit with 30 tele- lished using either a Veress needle and Optical
scope 10 mm and 5 mm Trocar or a Hasson trocar.
–– Atraumatic Graspers (×2) 5 mm The first 12 mm trocar is inserted on the ante-
–– Curved Scissors (×1) 5 mm rior axillary line between the anterior iliac spine
–– Bowel Clamp (×1) 5 mm and the subcostal margin. A 30° laparoscope is
–– Suction/irrigation device inserted and diagnostic laparoscopy is carried
–– Advance Energy Device (Thunderbeat, out. Two 5 mm trocars are inserted under vision
Olympus, Japan) on both sides of the 12 mm trocar. Trocars should
–– Suture passer be at least 8 cm away from the lateral edge of
–– Nonabsorbable suture (Polypropilene 0 or 1) RAD.
Assisted Rectus Diastasis Approximation:

LARDA) this can be utilized alone or with the
posterior endosuturing plication (Fig. 12).
After the recti mm approximation, an intraper-
itoneal mesh is positioned for reinforcement to
repair the concomitant ventral hernia that follows
the same surgical technique of the Laparoscopic
IPOM technique, similar to the complications
and postoperative care we refer to in the laparo-
scopic IPOM Chapter.
Since we do not have at this time random-
ized clinical trials to support and clinical
evidence, we will summarize our clinical expe-
Fig. 10 Nonabsorbable transfascial suture utilized to rience to validate our approach. RD is present
approximate large RD in about 18–20% of our primary midline her-
nia. Since 2013, we have started to consider
the repair of the RD as mandatory and we have
collected data from 89 patients (78 F; 11 M)
with a mean age of 37 years old. Among the
Female patients: all had at least two deliveries
and 85% had a cesarian section. Mean defect
size was (W2: 3.8 cm) with a mean length of
13 cm. we performed a posterior plication with
endosuturing in 33 pts. and in 56 we used trans-
fascial suture (LARDA Technique). Mesh was
utilized in all cases (65 pts. had 10 × 15 cm;
24 pts has a 15 × 20 cm); Mean VAS score was
2 (range 0–7) at 24 h and 1 at movement at
48 h. No complications were recorded and the
Fig. 11 An intracorporeal continuous suture with nonab- recurrence rate was 0 at 22 months follow-up.
sorbable material is utilized to approximate the edges of Satisfaction rate using Carolinas Comfort Scale
the recti mm score was very good in 96% of the patients.
In conclusion, the posterior approach either
Hernia defect and diastasis are identified and with LARDA or posterior endosuturing plica-
adhesiolysis is performed if needed. tion allows to correct umbilical hernia and rec-
Our alternative for the RAD closure involves tus diastasis concurrently. Patient with normal
either the use of nonabsorbable transfascial BMI with minimal skin excess and rectus dias-
suture (Fig. 10) or the closure of the posterior tasis are the best candidates. The minimal dis-
rectus muscle aponeurosis by a continuous non- section and the use of MIS improve the cosmetic
absorbable suture (Fig. 11). Suture plication of results. Without dissection of the supra-aponeu-
posterior can be performed using a single- or rotic space, we can reduce the incidence of
double-layer suture technique or a triangular seroma and skin infection and necrosis. Both
“mattress” running suture technique. techniques are feasible, safe with acceptable
For large RAD, we prefer the use of transfas- clinical outcome, and with a shorter learning
cial suture approximation (Laparoscopic-curve.
Fig. 12 Showing the use of transfascial suture for the closure of the defect (photo above) and the final results
Complications ostoperative Care, Follow-Up,

P
and Outcomes
Complications following surgery are mainly rep-
resented by seromas, hematomas, or wound com- Suction drains can be used and should be removed
plications, such as skin or flap ischemia, surgical when serosal output is less than 30–40 mL/24 h.
site infections, or hypertrophic scarring. There is no evidence suggesting the benefit of an
Dissection and suturing may be responsible. abdominal binder, but it can be considered to pro-
Complications may be more frequent when mesh vide compression and increase patient comfort
is used. postoperatively. Patients should avoid heavy lift-
ing for at least 4 weeks. Follow-up is indicated in 10. Lockwood T. Rectus muscle diastasis in males: pri-
mary indication for endoscopically assisted abdomi-
the first 3 months postoperative to rule out noplasty. Plast Reconstr Surg. 1998;101:1685.
seroma, collections, and recurrences, then as 11. van Keulen CJ, et al. The role of type III colla-
planned. Patient satisfaction after surgery is often gen in family members of patients with abdomi-
high and recurrence rate low but further long- nal aortic aneurysms. Eur J Vasc Endovasc Surg.
2000;20(4):379–85.
term RCTs are needed. 12. Blotta RM, et al. Collagen I and III in women with
diastasis recti. Clinics (Sao Paulo). 2018;73:e319.
13. McPhail I. Abdominal aortic aneurysm and diastasis
References recti. Angiology. 2008;59:736.
14. Ranney B. Diastasis recti and umbilical hernia causes,
recognition and repair. SDJ Med. 1990;43:5–8.
1. Brooks DC. Overview of Abdominal Wall hernias in
15. Reinpold W, Köckerling F, Bittner R, Conze J,
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Fortelny R, Koch A, Kukleta J, Kuthe A, Lorenz R,
2. Beer GM, Schuster A, Seifert B, et al. The normal
Stechemesser B. Classification of rectus diastasis—a
width of the linea alba in nulliparous women. Clin
proposal by the German hernia society (DHG) and the
Anat. 2009;22:706.
international Endohernia society (IEHS). Front Surg.
3. Mota P, Pascoal AG, Carita AI, Bo K. Normal width
2019;28:6.
of the inter-recti distance in pregnant and postpar-
16. Keshwani N, McLean L. Ultrasound imaging in
tum primiparous women. Musculoskelet Sci Pract.
postpartum women with diastasis recti: inter-rater
2018;35:34–7.
between-session reliability. J Orthop Sports Phys
4. Rath AM, Attali P, Dumal JL, Goldlust D, Zhang
Ther. 2015;45(9):713–8.
J, Chevrel JP. The abdominal linea alba: an
17. Akram J, Matzen SH. Rectus abdominis diastasis. J
anatomo-
radiologic and biomechanical study. Surg
Plast Surg Hand Surg. 2014;48:163.
Radiol Anat. 1996;18:281–8.
18. Nahas FX, Augusto SM, Ghelfond C. Should diastasis
5. Digilio MC, Capolino R, Dallapiccola B. Autosomal
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dominant transmission of nonsyndromic diastasis
19. Köhler G, Kuketina RR, Emmanuel K. Sutured repair
recti and weakness of the linea alba. Am J Med Genet
of primary small umbilical and epigastric hernias:
A. 2008;146A:254.
concomitant rectus diastasis is a significant risk factor
6. Okayasu I, Kajita A, Shimizu K. A variant form of
for recurrence. World J Surg. 2015;39:121–6.
median defect syndrome. Syndrome of combined
20. Bellido Luque J, et al. Totally endoscopic surgery
congenital defects involving the supraumbilical
on diastasis recti associated with midline hernias.
abdominal wall, sternum, diaphragm, pericardium,
The advantages of a minimally invasive approach.
and heart. Acta Pathol Jpn. 1978;28:287.
Prospective cohort study. Hernia. 2014;19:493–501.
7. Hsia M, Jones S. Natural resolution of rectus
21. Köhler G, Kuketina RR, Emmanuel K. Sutured repair
abdominis diastasis. Two single case studies. Aust J
of primary small umbilical and epigastric hernias:
Physiother. 2000;46:301.
concomitant rectus diastasis is a significant risk factor
8. Fernandes da Mota PG, Pascoal AG, Carita AI,
for recurrence. World J Surg. 2015;39:121–6. https://
Bø K. Prevalence and risk factors of diastasis recti
doi.org/10.1007/s00268-014-2765-y.
abdominis from late pregnancy to 6 months postpar-
22. Costa TN, Abdalla RZ, Santo MA, Tavares RRFM,
tum, and relationship with lumbo-pelvic pain. Man
Abdalla BMZ, Cecconello I. Transabdominal midline
Ther. 2015;20:200.
reconstruction by minimally invasive surgery: tech-
9. Benjamin DR, van de Water AT, Peiris CL. Effects of
nique and results. Hernia. 2016;20:257–65. https://
exercise on diastasis of the rectus abdominis muscle
doi.org/10.1007/s10029-016-1457-y.
in the antenatal and postnatal periods: a systematic
review. Physiotherapy. 2014;100:1.
Endo-laparoscopic Retromuscular
Repair
Enrico Lauro, Giovanni Scudo, and Salvatore Rizzo
Introduction The widened midline is cut and sutured by sta-

pling, bringing the two rectus muscles closer
Although few data exist to guide the management together and repairing the diastasis at the same
of rectus abdominis diastasis (RAD), during past time.
decades many articles were published to describe Section of the linea alba creates a retromuscu-
techniques to correct RAD and concomitant lar box where to place the mesh in a sublay
abdominal midline defects [1–4]. Among these, position.
stapled techniques are acquiring an increasing
interest [5–8].
Main common points of these techniques are: Indications
• Respect of Rives-Stoppa principles Endo-laparoscopic stapled repair must be consid-

• Use of staplers to repair the widened linea ered for:
alba and keep together the rectus muscles at
the same time • Small, single, and multiple midline or inci-
• Sublay mesh reinforcement sional hernias (W1, according to EHS classifi-
cation) associated with RAD up to 5 cm width
Retromuscular space can be accessed from the • Patients fit for general anesthesia
Retzius space, as during TEP procedure, using a • Absence of contraindications to laparoscopy
space maker balloon or directly by blind
dissection.
An infra-umbilical incision is an effective Contraindications
alternative to gain the same retromuscular space.
The space between rectus muscles and poste- • Large midline defects > W2, in accord to EHS
rior sheath is then dissected endoscopically. classification (relative)
• Previous retromuscular mesh repair for
abdominal hernias
E. Lauro (*) · G. Scudo • Skin excess or need for abdominoplasty
General Surgery Division, St. Maria del Carmine
Hospital, Rovereto, Italy • Major loss of abdominal domain
e-mail: enrico.lauro@apss.tn.it • Pediatrics patients
S. Rizzo • Cancer patients
General Surgery Division, Cavalese Hospital, • Pregnancy or desire for future pregnancy
Cavalese, Italy • Portal hypertension
https://doi.org/10.1007/978-981-19-3755-2_65
470 E. Lauro et al.
• Previous placement of a peritoneal dialysis We prefer to use the Veress needle at Palmer’s
catheter (relative) point. A 5 mm port is placed on the left flank lat-
• Emergency setting (relative) eral to the semilunar arcuate line, and laparo-
scopic exploration of the abdomen is then
performed to assess the real defect to treat. If
Preoperative Assessment needed, other 5 mm ports can be positioned to
reduce all hernial contents. At the end of this
• Careful clinical history and physical phase, the intra-abdominal pressure is reduced to
examination a lower value of 6–8 mmHg.
• CT scan without contrast, at rest and during
Valsalva’s maneuver
• Routine investigations according to hospital Endoscopic Phase
protocols
• Prophylactic antibiotics according to hospital It starts by obtaining access to the retromuscular
protocols space (according to the chosen technique). We
• Previous stop of any anticoagulant according prefer to perform an infra-umbilical 4 cm inci-
to its wash-out time sion, reducing eventual umbilical hernias if pres-
• Administration of Low-molecular-weight ent. Access to the retromuscular space is gained
heparin (LMWH) if indicated bilaterally by small incisions on the anterior rec-
• Gastric and Bladder decompression tus muscles fascia.
The two branches of a linear stapler are
inserted respectively beneath the right and the
left rectus muscles (Fig. 1).
OT Setup
• Patient in standard supine position (split legs

optional)
• Monitor is on the patient’s head side
• Laparoscopic Instrumentation required:
–– 30° scope 5 mm
–– 1 Trocar 5 mm
–– 1 monoport
–– 2 atraumatic graspers 5 mm
–– 1 Veress needle (optional)
–– 1 curved Maryland dissector 5 mm
–– 1 curved scissor
–– 1 bipolar forceps
–– 1 hook diathermy (optional)
–– Suction/irrigation device
Surgical Technique: How We Do It
Laparoscopic Phase
Pneumoperitoneum is induced by the closed

technique. Fig. 1 Insertion of Stapler beneath the rectus muscle
Endo-laparoscopic Retromuscular Repair 471
The Stapler, placed in the retromuscular space, We usually do not fix the mesh, but fibrin glue or
is then fired cranially and, after been reloaded, a self-gripping mesh is an option (Fig. 8).
caudally towards the pubis (Fig. 2). Finally, a laparoscopic check is performed to
A monoport is placed through the infra- exclude breaches in the peritoneum.
umbilical incision to proceed with the endoscopic
retromuscular dissection (Fig. 3).
The neurovascular bundles must be identified
and preserved (Fig. 4).
Using endoscopic staplers, the widened linea
alba is cut and sutured bringing the rectus mus-
cles closer together (Fig. 5).
The retromuscular space is prepared to obtain
a single chamber from the xiphoid to the supra-
pubic region or exceeding the defect for at least
4 cm (Fig. 6); it is highly recommended for a
laparoscopic check before stapling, to avoid
bowel injuries.
In case of large defects, an oversewn suture of
the anterior plication is performed in order to
reinforce the stapled suture and reduce the gap
between the two rectus muscles (Fig. 7).
Once the retromuscular space is prepared,
measurements are taken to choose the mesh size.
Fig. 3 Monoport at infra-umbilical incision
Fig. 4 Retromuscular space dissection
Fig. 2 Firing of stapler in the retromuscular space Fig. 5 Stapled midline plication
472 E. Lauro et al.
• Intraoperative complications:
• In case of posterior fascia breaches, repair can
be attempted by endoscopic approach to avoid
intraperitoneal mesh exposure.
• Bowel injuries need immediate treatment by
suture or bowel resection.
• Muscular bleeding is a rare complication and
Fig. 6 Final view of the retromuscular space can be approached endoscopically or, in case of
massive bleeding, converting to open
technique.
• Postoperative complications:
• Small retromuscular hematomas can be
treated conservatively. In case of deep epigas-
tric vessel bleeding, we suggest an urgent
angiographic treatment.
• Seromas can be managed conservatively,
while chronic or symptomatic seromas can be
aspirated in an aseptic setting.
• Chronic pain can require further investiga-
Fig. 7 Ower-sewn suture of the anterior stapled plication tions and specialistic management.
with a 2/0 barbed wire
Postoperative Care
• Diet and mobilization are resumed starting on

the first postoperative day
• Analgesia is prescribed according to hospital
protocol
• Discharge is feasible as soon as possible,
according to diet tolerance, pain control, and
adequate mobilization of the patient
Fig. 8 Retromuscular mesh placement • If closed-suction drainage is present, it can
be removed when output is less than
At the end of the procedure, the intraperito- 50 cc/24 h
neal port is removed from the peritoneum into the • All patients are advised to wear an abdominal
retromuscular space, to place a closed-suction binder for a period of at least 1 month after
drain. operation and avoid weight lifting for at least
The monoport is now retracted, and a suture of 2 months
the anterior rectus sheath is done with small bites
technique through the infra-umbilical incision.
Skin closure completes the operation.
Endo-laparoscopic Retromuscular Repair 473
References ated with midline hernias. The advantages of a mini-

mally invasive approach. Prospective cohort study.
1. Palanivelu C, Rangarajan M, Jategaonkar PA, et al.
s10029-014-1300-2.
Laparoscopic repair of diastasis recti using the
5. Abdalla RZ, Garcia RB, da Costa RID, Abdalla
'Venetian blinds' technique of plication with pros-
BMZ. Treatment of mid-line abdominal wall hernias
thetic reinforcement: a retrospective study. Hernia.
with the use of endo-stapler for mid-line closure. Arq
2009;13(3):287–92.
Bras Cir Dig. 2013;26(4):335–7.
2. Muas DMJ, Palmisano E, Poa Santoja G, et al.
6. Carrara A, Lauro E, Fabris L, Frisini M, Rizzo
Preaponeurotic endoscopic repair (REPA) as treatment
S. Endo-laparoscopic reconstruction of the abdominal
of the diastasis of the recti associated or not to hernias
wall midline with linear stapler, the THT technique.
of the middle line. Multicenter study. Rev Hispanoam
Early results of the first case series. Ann Med Surg.
2019;38:1–7.
rhh.194.
7. Costa TN, Abdalla RZ, Santo MA, Tavares RRFM,
3. Köckerling F, Botsinis MD, Rohde C, Reinpold W,
Abdalla BMZ, Cecconello I. Transabdominal midline
Schug-Pass C. Endoscopic-assisted linea alba recon-
reconstruction by minimally invasive surgery: tech-
struction: new technique for treatment of symp-
nique and results. Hernia. 2016;20(2):257–65.
tomatic umbilical, trocar, and/or epigastric hernias
8. Moore AM, Anderson LN, Chen DC. Laparoscopic
with concomitant rectus abdominis diastasis. Eur
stapled sublay repair with self-gripping mesh: a simpli-
Surg. 2017;49(2):71–5. https://doi.org/10.1007/
fied technique for minimally invasive Extraperitoneal
s10353-017-0473-1.
ventral hernia repair. Surg Technol Int. 2016;29:131–9.
4. Bellido Luque J, Bellido Luque A, Valdivia J, et al.
Totally endoscopic surgery on diastasis recti associ-
Endoscopic Subcutaneous Onlay
Laparoscopic Approach
Andreuccetti Jacopo, Di Leo Alberto,

and Enrico Lauro
Introduction Indications
In recent years, abdominal wall surgery has • Small/medium (≤4 cm) primitive hernias or
shown a clear interest in reproducing traditional multiple defects of the abdominal wall mid-
open techniques and avoiding intraperitoneal line (umbilicus and/or epigastric hernia)
mesh placement. The endoscopic Subcutaneous associated with rectus muscles diastasis
Onlay Laparoscopic Approach (SCOLA) is very >2 cm
popular in South American countries, especially • Patients fit for general anesthesia
for small umbilical and epigastric hernias with
concomitant rectus muscles diastasis. In these
cases, a full midline reconstruction should be Contraindications
scheduled, because hernia repair alone is affected
by a higher recurrences rate compared to simulta- • Midline defects ≥5 cm
neous hernia and diastasis repair [1–5]. Through • Excess of skin and/or subcutaneous tissue
an endoscopic dissection of the preaponeurotic • BMI >30 kg/m2
subcutaneous space is possible to reconstruct the • Complex hernias
abdominal wall by placing an onlay prosthesis in • Loss of abdominal domain
those patients without excess skin or subcutane- • Desire for pregnancy
ous tissue. Although SCOLA repair is safe and
feasible to correct diastasis recti and symptom-
atic midline hernias with excellent cosmetic Preoperative Assessment
results, seroma and abdominal numbness are fre-
quent complications. • Careful history and physical examination
• Routine investigations according to hospital
A. Jacopo (*) protocols
General Surgery 2, ASST Spedali Civili of Brescia, • Prophylactic antibiotics according to hospital
Brescia, Italy protocols
e-mail: jacopo.andreuccetti@asst-spedalicivili.it
• Suspension of any anticoagulant according to
D. L. Alberto its wash-out time
U.O. di Chirurgia Generale, Ospedale San Camillo,
Trento, Italy • Ultrasound or CT scan (without contrast at
rest and during Valsalva’s maneuver)
E. Lauro
General Surgery Division, St. Maria del Carmine • Preoperative antiseptic shower
Hospital, Rovereto, Italy • Prophylactic antibiotics
https://doi.org/10.1007/978-981-19-3755-2_66
476 A. Jacopo et al.
OT Setup (Fig. 1) –– The surgeon places himself between the

patient’s legs.
• Laparoscopic (Lps) Instrumentations –– The endoscopic equipment is positioned to
–– Lps camera (10 mm, 30°) the right of the patient.
–– 1 × 11 mm trocar (or balloon tip trocar) • Essential Steps in Synthesis
–– 2 × 5 mm trocars –– Trocars setup (Figs. 2 and 3).
–– Lps bipolar forceps –– Creation of a pyramid-shaped preaponeu-
–– Lps curved scissor rotic work chamber (Fig. 4).
–– 2 × Johann forceps –– Reduction of the ventral hernia (Fig. 5).
–– Lps needle holder –– Plication of the linea alba (Fig. 6).
–– Suture for linea alba plication (2–0 or 0 –– Mesh positioning and fixation (Figs. 7, 8,
absorbable barbed suture) and 9).
–– Prosthesis (lightweight and large porous
mesh)
–– Fibrin glue
• Patient’s Position (Figs. 2 and 3)
–– The patient is positioned supine on the sur-
gical table with the legs lower than the hip’s
level in order to avoid the fighting between
surgeon’s hands and patient’s limbs.
Fig. 3 Patient’s position
Fig. 1 OT Setup
Fig. 4 Creation of a pyramid-shaped preaponeurotic

Fig. 2 Patient’s position work chamber
Endoscopic Subcutaneous Onlay Laparoscopic Approach 477
Fig. 5 Reduction of the ventral hernia in abdomen

Fig. 9 Anchoring the umbilicus
• Description of the technique

A surgical incision is made in the suprapubic
region on the midline. After identifying the apo-
neurotic fascia, a small workspace is created with
finger dissection and the first 11 mm trocar is
there positioned (a balloon tip Trocar is an
option). A subcutaneous chamber is created
throughout blunt dissection using the camera, to
the right and then to the left towards the anterior
Fig. 6 Plication of the linea alba superior iliac spines. The other two 5 mm trocars
are now positioned obtaining an optimal triangu-
lation. The dissection proceeds in the preaponeu-
rotic space separating the anterior rectus sheath
and subcutaneous tissue, preserving the perforat-
ing vessels (Fig. 4). During the subcutaneous
space dissection hernias, defects are identified,
and their content is reduced (Fig. 5). The dissec-
tion extends up to the xiphoid. The linea alba pli-
cation is performed by suturing the medial
margins of the anterior fascia of the rectus mus-
cles with a barbed running suture (Fig. 6). A fixed
macroporous lightweight mesh is placed onlay
Fig. 7 Final aspect after midline plication and defect clo- according to the dimension of the plane (Figs. 7
sure. Measuring the prosthesis width
and 8). The last step of the intervention involves
anchoring the umbilicus on the fascial plane
(Fig. 9). If a suction drain is used it is held in
place until the output is less than 30 cc/24 h.
Postoperative Care
• All patients are prescribed an abdominal

binder to wear for about 2 months
• Analgesia is required
• Discharge is possible even after 24 h
Fig. 8 Mesh positioning • Advised against lifting weight for 3 months
478 A. Jacopo et al.
References hernias. Surg Endosc. 2019;33(6):1777–82. https://

doi.org/10.1007/s00464-018-6450-3.
4. Claus CMP, Malcher F, Cavazzola LT, et al.
1. Reinpold W, Köckerling F, Bittner R, et al.
Subcutaneous onlay laparoscopic approach (SCOLA)
Classification of rectus diastasis-a proposal by the
for ventral hernia and rectus abdominis diasta-
German hernia society (DHG) and the international
sis repair: technical description and initial results.
Endohernia society (IEHS). Front Surg. 2019;6:1.
Arq Bras Cir Dig. 2018;31(4):e1399. https://doi.
https://doi.org/10.3389/fsurg.2019.00001.
org/10.1590/0102-672020180001e1399.
2. Muas DMJ, Palmisano E, Poa Santoja G, et al.
5. Bellido Luque J, Bellido Luque A, Valdivia J, et al.
Preaponeurotic endoscopic repair (REPA) as treatment
Totally endoscopic surgery on diastasis recti associ-
of the diastasis of the recti associated or not to hernias
ated with midline hernias. The advantages of a mini-
of the middle line. Multicenter study. Rev Hispanoam
mally invasive approach. Prospective cohort study.
rhh.194.
s10029-014-1300-2.
3. Juárez Muas DM. Preaponeurotic endoscopic repair
(REPA) of diastasis recti associated or not to midline
Part XIX
Other Hernias
Minimally Invasive Surgery
for Diaphragmatic Hernia
Hrishikesh Salgaonkar, Kanagaraj Marimuthu,

Alistair Sharples, Vittal Rao,
and Nagammapudur Balaji
Diaphragmatic hernia (DH) is a rare entity, more The single most important factor is due to the
commonly seen in children as compared to pressure gradient between the abdominal and
adults. It is classified as congenital or acquired. thoracic cavities. During respiratory cycle, this
Most common cause of acquired hernia is follow- may reach up to 100 mm of Hg and contributes
ing trauma. Management of DH is primarily sur- to herniation of abdominal contents into the tho-
gical repair which can be performed by racic cavity [1]. DH can be classified as congeni-
laparotomy, laparoscopy, thoracotomy, or thora- tal or acquired [2]. Congenital DH is seen mainly
coscopy. Due to the rarity of the disease, there is in pediatric population and occurs due to failure
a paucity of data in the literature regarding the of the fusion of foraminas of diaphragm. In
best approach for the repair. With the advent of Bochdalek hernia, there is an incomplete fusion
laparoscopy or thoracoscopy, these are the pre- of posterolateral foramina and in Morgagni her-
ferred options as it offers us all the known bene- nia, it is at the anterior midline through the
fits associated with minimally invasive surgery sterno-coastal region. Acquired DH is most com-
(MIS). For the scope of this chapter, our focus monly traumatic in origin, mainly due to pene-
will be on the role of thoracoscopy and laparos- trating or blunt trauma to the abdomen or thorax.
copy in the management of adult DH, the techni- Spontaneous DH is a rarity where the patient
cal details, and its associated complications. denies any history of trauma or symptoms and
accounts for less than 1% of cases [3, 4]. But a
possibility of a previously forgotten trauma can-
Introduction not be ruled out completely. The presentation of
DH can be acute or chronic. For chronic DH, the
An important muscle of respiration, the dia- classification criteria concerns the temporal
phragm forms a physical wall which separates parameter of its development and diagnosis. As
the contents of the chest from the abdomen. In per Carter’s Scheme [5].
diaphragmatic hernia (DH), there is herniation
of abdominal viscera into the pleural space 1. Acute phase (time between the original
through a weakness or defect in the diaphragm. trauma and the patient’s recovery)
2. Latent phase (time post-recovery during
which patient may or may not be symptomatic
H. Salgaonkar (*) · K. Marimuthu · A. Sharples · and obstructive phase)
V. Rao · N. Balaji
Department of Bariatric and Upper GI Surgery, 3. Obstructive phase (when contents become
University Hospitals North Midlands, incarcerated with potential risk of ischemia,
Stoke-on-Trent, UK necrosis, and perforation)
https://doi.org/10.1007/978-981-19-3755-2_67
The diagnosis of traumatic DH is often sis, pleural effusion, or hydro-pneumothorax. If a

delayed as at the time of the accident or trauma it nasogastric tube is inserted, very commonly this
is difficult to detect a small defect or rent in the may be seen in the chest in defect on the left side
diaphragm [6]. Most symptoms are masked due if stomach has herniated through. A CT scan of
to the associated symptoms from the traumatic chest and abdomen or MRI may be helpful when
injury [5, 7]. It only raises suspicion when com- diagnosis is uncertain.
plications of DH occur, e.g., gastrointestinal Once diagnosed, irrespective of symptoms it
obstruction, strangulation of contents, or cardio- is advisable to offer surgery if the patient is fit.
pulmonary compromise. Traumatic DH is more This can be via laparotomy, thoracotomy, lapa-
common on left side (80%) and can be bilateral roscopy, or thoracoscopy or a combined approach
in 1–3% of cases. The left preponderance is based on the surgeon’s preference, anatomic
thought to be due to the protective effect of the location of defect, degree of infra-diaphragmatic
bare area of liver dissipating the force of the adhesions, and previous abdominal repair [9]. It
injury. The incidence of DH post penetrating is not advisable to delay the surgery as this may
trauma is almost double after a gunshot injury lead to complications, e.g., volvulus, incarcera-
(20–59%) as compared to stab wounds (15–32%) tion, strangulation, etc. The goal is to reduce the
[8]. Classically a chronic DH is a sequelae of an contents back into the abdominal cavity and
undiagnosed and untreated diaphragmatic injury repairing the defect in the diaphragm. Minimal
while managing an acute traumatic event. Both invasive surgery in the form of laparoscopy or
penetrating and blunt thoracoabdominal injuries thoracoscopy offers us all the benefits in terms of
may cause a DH. lesser pain, shorter hospitalization, reduced
The clinical features of DH differ based on the respiratory complications, and early return to
location of the hernia and the organs herniating work [3, 9]. Although data from randomized con-
through it. Most common organs involved are the trol trials is lacking results of both thoracoscopy
liver and gallbladder on the right side and the or laparoscopy have been found to be comparable
stomach, colon, and small bowel on the left side. [9]. Laparoscopy in particular by delineating
In large hernia, solid organs like liver and spleen clear anatomy, better working space is increas-
may also herniate. DH is often asymptomatic or ingly thought to be a safe and feasible option to
produces very mild symptoms, till serious com- repair DH [10].
plications like obstruction or strangulation mani- Acute DH with obstruction/strangulation
fest. It is not unusual for the patient to present or Acute traumatic DH: In an acute scenario,
months to years after the index injury. surgical approach should be immediate without
Symptomatology may be related to respiratory any delay. Traditionally this would involve a lap-
tract, gastrointestinal organs, or a nonspecific arotomy or thoracotomy. Use of prosthesis when
general pain. When complications occur, patient contaminated field is present is debatable. Use of
may have severe respiratory, gastrointestinal, or biological mesh may be considered. For the
cardiovascular symptoms which may mimic a scope of this chapter, we would keep our focus on
tension pneumothorax also. minimal invasive modalities.
In some cases, a DH may be discovered inci-
dentally on a radiological examination performed
for unrelated reasons. A high index of suspicion Preoperative Work-Up
is necessarily combined with a detailed history,
thorough clinical examination, proper interpreta- A thorough preoperative assessment is required
tion of the radiological images namely chest to assess fitness to withstand the surgery, nutri-
radiograph which is a preliminary investigation tional assessment, and optimization of medical
ordered in most outpatient or emergency setup. comorbidities. This includes routine blood, uri-
Usual findings are loss of diaphragmatic integrity nalysis, chest radiograph, barium swallow if
with bowel haustrations or gas shadows within needed, or a CT scan. If a history of smoking is
thorax, mediastinal shift to normal side, atelecta- present it is advisable to abstain immediately.
Minimally Invasive Surgery for Diaphragmatic Hernia 483
Acute presentation of DH is a true surgical emer- lary line, one additional 5 mm port in the midline
gency and we may need to proceed to surgery epigastric region for assistant. For left side DH,
immediately. Correction of dehydration and elec- five ports are generally used. A 10/12 mm port
trolyte abnormalities if any should be done. In just above the umbilicus, two working lateral
left side hernias, it is advisable to decompress the ports on either side in the midclavicular line at
stomach with nasogastric tube. Counsel the the level of umbilicus, 5 mm substernal port for
patient regarding the risk of complications with liver retraction, and additional port left side later-
particular emphasis on recurrence. ally along the anterior axillary line for assistant.
Always start by performing a general exami-
nation of the peritoneal cavity to exclude any
Operative Technique: Laparoscopy other pathology, e.g., other abdominal wall her-
nia, adhesions, or what organs are herniating to
Theater layout and patient position: The patient the defect (Fig. 1). Visualize the entire diaphragm
is placed in supine position with split legs. Secure on both sides and assess for contents of the DH.
the patient safely to the operative table with Reducing the contents and delineating the
straps at mid-thigh levels, to both legs separately defect: Use nontraumatic graspers to retract bow-
and foot support if patient is morbidly obese. The els caudally away from the operative field.
stability should be tested preoperatively by plac- Contents of the hernia are gently reduced using
ing patient in anti-Trendelenburg position before nontraumatic graspers (Fig. 2).
starting the surgery. The arms are tucked by the
patient side. Compression stockings and pneu-
matic compression devices are applied to both
legs until unless contraindicated. The surgeon
stands in between the legs, camera operator on
the right side, and another assistant on the left in
left side DH. On right side DH, the camera opera-
tor and assistant change their positions. It is ideal
to have two monitors one on either side of the
patient’s head. If only one monitor is present
place it above the affected side shoulder.
Abdominal access and techniques: Creation of
pneumoperitoneum can be done using a Veress
needle, by direct trocar entry (Optical entry) or Fig. 1 Diaphragmatic hernia with stomach, liver, and
open Hasson’s technique. Insufflating the abdo- spleen pulled up into the defect
men to 12–14 mmHg. The table is then placed in
anti-Trendelenburg position 25–300. This allows
better visualization of the upper abdominal cav-
ity and tissue spaces that need to be dissected.
Rest trocars are placed under vision. A liver
retraction device is placed through one of these
port sites, usually substernal to retract the liver if
it is not herniating. The port position and num-
bers vary slightly depending upon the side of the
hernia. Total 4–5 trocars technique is used based
upon the side of DH, the contents herniating
through. On the right side DH, a 10/12 mm port
just above the umbilicus for scope, two additional
ports laterally on the right side one in the midcla- Fig. 2 Gentle traction with nontraumatic graspers to
vicular line and another along the anterior axil- reduce the contents
In acute cases the contents especially stomach, Defect closure: With regards to defect closure,
small bowel, or colon may be edematous and can some surgeons prefer simple suturing of the
be easily damaged with serosal tears or enteroto- defect, whereas others prefer to additionally rein-
mies. Special care is taken while handling and force the defect with prosthetic material.
reducing solid organs, e.g., spleen if seen herniat- However, it is generally agreed that defects which
ing to avoid hemorrhage. Any adhesions between are larger than 20–30 cm2 do require the use of
the herniated organs and sac which are continuous prosthesis [11]. The author prefers the use of
with the pleural lining should be meticulously sep- barbed suture or ethibond to close the defect.
arated using an energy device as per surgeon pref- Meticulous defect closure is attempted in all
erence. It is not uncommon to end up making cases (Fig. 3).
multiple openings in the pleural lining. Any open- If required peritoneal flaps or muscular flaps
ings in the pleural lining can be sutured using 3–0 can be utilized. In addition to providing a flat sur-
absorbable sutures. In difficult cases, a thoracos- face for prosthesis placement, it prevents mesh
copy may be performed additionally to aid the extrusion through the defect [12]. Once the defect
release of adhesions of herniated abdominal con- is closed, different types of prosthesis can be
tents from the thoracic cavity. In longstanding DH, used for reinforcement. In the literature review,
the lung on the affected side is hypoplastic in many polypropylene, composite mesh, and biological
cases. Once the defect is delineated, clear out any meshes have been used. In the authors opinion,
adhesions around the edges so as to gain space for composite or biological mesh should be used.
suturing the edges and mesh placement/fixation. At Although more expensive, they are preferred due
this stage, if required one can pass an intercoastal to lower infection rates and less risk of erosion
drain under vision into the pleural cavity. In large into hollow viscus [13]. Like any hernial repair,
defects this may involve mobilizing the splenic the mesh should overlap the defect by at least
flexure on the left side, Gerota’s fascia or the trian- 5 cm all around to reduce risk of recurrence.
gular ligaments of the liver. In cases of large and Until and unless contraindicated, we always rein-
redundant hernial sacs, excess sacs can be excised force the closed defect with a prosthesis to reduce
to facilitate proper closure. If eventration of dia- the risk of recurrence. Also, placing the mesh on
phragm is present, we can plicate the diaphragm the peritoneal surface of diaphragm by physiol-
with polypropylene or ethibond sutures. The plica- ogy of intra-abdominal pressure keeps the mesh
tion helps to bring the diaphragm to the desired opposed to the defect (Laplace’s law). The mesh
level which will help us during defect closure. is then fixed using sutures, tackers, or glue
Fig. 3 Completely delineate and close the defect of diaphragmatic hernia

cover is decided on a case-to-case basis. All

patients should undergo a postoperative chest
radiograph. Intercoastal drain is removed based
upon the quantity of draining fluid from the pleu-
ral cavity, resolution of pneumothorax, and lung
expansion. Regular follow up is needed, ideally
after 1 week, every 3 months in the first year, and
then annually for 4–5 years after surgery. A
detailed clinical examination and chest radio-
graph should be performed.
Fig. 4 Mesh reinforcement and fixation over the defect

Complications
(Fig. 4). While tackers are the most commonly Fatal intraoperative complications such as failure
used modality, it is advisable to use them care- to return viscera to the abdominal cavity, irrepa-
fully so as to avoid injury to vital structures in the
rable bowel abnormalities, e.g., ischemia, gan-
vicinity. grene, etc., failure to repair large defects, and
Thoracoscopy: A thoracic approach may be difficulty maintaining ventilation and oxygen-
preferred to treat recurrent diaphragmatic hernia, ation ultimately leading to mortality are not
following a previous abdominal repair. It can also uncommon particularly in emergency scenarios.
be used in combination with laparoscopy, espe- Routine complications of any thoracoscopic or
cially in presence of dense adhesions between gastrointestinal surgery such as chest infection,
the contents and the thoracic cavity inner lining wound infections, bleeding, incisional hernia,
[14]. It is also easier to plicate diaphragmatic adhesions, and postoperative ileus are reported.
eventration thoracoscopically as compared to While performing adhesiolysis, bleeding and vis-
laparoscopically. If a thoracoscopic or laparo- ceral injuries can occur. Pneumothorax and pleu-
thoracoscopic approach is planned it is advisable ral effusion are common complication.
to perform general anesthesia with a double- Longstanding DH predisposes patients to pulmo-
lumen tube to achieve single-lung ventilation. nary hypertension. Although there is a paucity of
evidence from randomized control trials, mini-
mal invasive modalities of managing DH offer us
Postoperative Care all the benefits namely reduced pain, shorter hos-
pitalization, early return to work, respiratory, and
Patient who has preoperative respiratory distress wound-related complications.
(emergency scenarios) or a severely hypoplastic Recurrence: The incidence of recurrence is
lung on affected side, recovery from anesthesia debatable. In congenital DH this ranges from 3 to
may be difficult and may need ventilatory sup- 50% in various studies. It is advisable to repair a
port postoperatively. Similarly, in patients where recurrent DH after a laparotomy or laparoscopy
bowel resection is performed, e.g., strangulation with thoracoscopic approach [15].
of contents, etc., may need nutritional support in Bowel obstruction: Handling of intra-
the form of TPN or enteric feeding. abdominal viscera invariably leads to adhesions,
In elective setup, as per ERAS protocol (Early which may progress to bowel obstruction. These
recovery after surgery) adequate analgesia and are more common after laparotomy as compared
anti-emetics are prescribed. Early mobilization to laparoscopic DH repair [16, 17].
and feeds are encouraged. Postoperative anti- Long-term morbidity: Significant proportions
thrombotic prophylaxis based upon hospital rec- of patients with longstanding DH suffer from
ommendations should be followed. Anti-microbial long-term complications even after surgical
repair. These are chronic respiratory disease, pul- References

monary hypertension, gastroesophageal reflux
disease, and musculoskeletal deformities (more 1. İçme F, Vural S, Tanrıverdi F, Balkan E, Kozacı N,
Kurtoğlu GÇ. Spontaneous diaphragmatic hernia: a
common after thoracotomy). case report. Eurasian J Emerg Med. 2014;13:209–11.
2. de Meijer VE, Vles WJ, Kats E, den Hoed
PT. Iatrogenic diaphragmatic hernia complicat-
Conclusion ing nephrectomy: top-down or bottom-up? Hernia.
2008;12(6):655–8.
3. Gupta S, Bali RK, Das K, Sisodia A, Dewan RK,
Minimally invasive surgery for DH repair offers Singla R. Rare presentation of spontaneous acquired
us all the routine benefits such as magnified diaphragmatic hernia. Indian J Chest Dis Allied Sci.
vision, shorter hospitalization, and reduced 2011;53(2):117–9.
4. Gupta V, Singhal R, Ansari MZ. Spontaneous
wound and pulmonary complications as com- rupture of the diaphragm. Eur J Emerg Med.
pared to open methods. Laparoscopic or thoraco- 2005;12(1):43–4.
scopic repair of DH is a safe and effective method 5. Carter BN, Giuseffi J, Felson B. Traumatic dia-
for managing adult diaphragmatic hernias, espe- phragmatic hernia. Am J Roentgenol Radium Ther.
1951;65(1):56–72.
cially in experienced hands. 6. Bani Hani MN. A combined laparoscopic and endo-
scopic approach to acute gastric volvulus associated
Practical Tips with traumatic diaphragmatic hernia. Surg Laparosc
Endosc Percutan Tech. 2008;18(2):151–4.
7. Dwari AK, Mandal A, Das SK, Sakar S. Delayed
• Having a trained and regular team assisting presentation of traumatic diaphragmatic rupture with
during the surgery cannot be herniation of the left kidney and bowel loops. Case
over-emphasised. Rep Pulmonol. 2013;2013:814632.
• Combining laparoscopy and thoracoscopy is a 8. Ahmed N, Jones D. Video-assisted thoracic sur-
gery: state of the art in trauma care. Injury.
good option especially when adhesions are 2004;35(5):479–89.
present between the contents and the thoracic 9. Saroj SK, Kumar S, Afaque Y, Bhartia AK, Bhartia
cavity. VK. Laparoscopic repair of congenital diaphragmatic
• Insertion of additional trocars and conversion hernia in adults. Minimal Invas Surg. 2016;2016:1–5.
10. Thoman DS, Hui T, Phillips EH. Laparoscopic
to open technique in difficult scenarios should diaphragmatic hernia repair. Surg Endosc.
not be considered as failure of surgery. 2002;16(9):1345–9.
• For defects closed under tension or defects 11. Jee Y. Laparoscopic diaphragmatic hernia repair
larger than 10 cm use a prosthetic using expanded polytetrafluoroethylene (ePTFE) for
delayed traumatic diaphragmatic hernia. Wideochir
reinforcement. Inne Tech Maloinwazyjne. 2017;12(2):189–93.
• In cases where the defect cannot be closed, 12. Palanivelu C, Jani KV, Senthilnathan P, Parthasarathi
local muscle flaps (intercostals, latissimus R, Madhankumar MV, Malladi VK. Laparoscopic
dorsi) or Intraperitoneal fascial flaps (Toldt’s) sutured closure with mesh reinforcement of incisional
hernias. Hernia. 2002;11(3):223–8.
are performed to cover the defect with help of 13. Esposito F, Lim C, Salloum C, Osseis M, Lahat
plastic surgeons. E, Compagnon P, et al. Diaphragmatic hernia fol-
• Diaphragmatic hernia is a rare diagnosis. lowing liver resection: case series and review of
Surgical results are best in experienced hands. the literature. Ann Hepatobiliary Pancreat Surg.
2017;21(3):114–21.
These are to be borne in mind before offering 14. Chauhan SS, Mishra A, Dave S, Naqvi J, Tamaskar S,
surgery to patients, especially in an elective Sharma V, et al. Thoracolaparoscopic management of
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15. Keijzer R, van de Ven C, Vlot J, et al. Thoracoscopic
Acknowledgments Kind regards to Dr. Sunil Kumar
repair in congenital diaphragmatic hernia: patching is
Nayak, Department of Minimal invasive surgery, GEM
safe and reduces the recurrence rate. J Pediatr Surg.
Hospital and Research Centre, Coimbatore for providing
2010;45(05):953–7.
all the intraoperative images.
16. Putnam LR, Tsao K, Lally KP, et al. Congenital 17. Davenport M, Rothenberg SS, Crabbe DCG, Wulkan
diaphragmatic hernia study group and the pedi- ML. The great debate: open or thoracoscopic repair
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invasive vs open congenital diaphragmatic hernia Pediatr Surg. 2015;50(02):240–6.
repair: is there a superior approach? J Am Coll Surg.
2017;224(04):416–22.
Laparoscopic Parastomal Hernia
Repair
Isaac Seow-En, Yuan-Yao Tsai,

Introduction significant enough to warrant surgical interven-

tion, including incarceration, strangulation, and
Parastomal hernia is an incisional hernia result- perforation. The bulging around the stoma can
ing from an abdominal wall stoma creation [1]. also cause result in difficulty applying the
The published incidence of parastomal hernia stoma appliance, resulting in leakage and skin
varies widely, with 2–28% and 4–48% affecting irritation [2].
end ileostomies and end colostomies, respec- As with other types of incisional hernia, risk
tively, depending on the severity of the hernia, factors associated with parastomal hernia develop-
method of diagnosis, and the duration of fol- ment can be categorized into patient- or technique-
low-up [2]. Loop stomas have a much lower related. Patient factors include underlying
incidence of parastomal herniation, as these comorbid conditions which raise intra-abdominal
tend to be reversed before a hernia can develop. pressure, adversely affect wound healing and
The risk of herniation is cumulative with time nutrition, or predispose to wound infection.
but appears to be highest within 2 years of Obesity with a BMI ≥ 25 kg/m2 has also been
ostomy formation. Most patients are asymp- found to be an independent risk factor [3].
tomatic or have mild complaints such as inter- Surgery-related or technical factors include
mittent discomfort or sporadic obstructive the site of stoma creation, the size of the tre-
symptoms, but many eventually have symptoms phine, intraperitoneal versus extraperitoneal
route, and the prophylactic use of a mesh. It is
I. Seow-En a common belief that stomas formed through
Department of Colorectal Surgery, Singapore General the rectus abdominis muscle have lower hernia
Hospital, Singapore, Singapore rates than those formed lateral to the muscle.
Division of Colorectal Surgery, China Medical However, a 2003 review [2] observed that only
University Hospital, Taichung, Taiwan one study [4] out of six comparing the two
Y.-Y. Tsai approaches found any significant benefit in the
Division of Colorectal Surgery, China Medical transrectus positioning. A 2019 Cochrane
review similarly could not demonstrate a lower
W. T.-L. Chen (*) rate of hernia if the stoma were placed through
Division of Colorectal Surgery, Department of
versus lateral to the rectus muscle [5]. It is
Surgery, China Medical University Hsinchu Hospital,
Zhubei City, Hsinchu County, Taiwan noteworthy that another recent meta-analysis
e-mail: wtchen@mail.cmuh.org.tw showed a significantly reduced incidence of

https://doi.org/10.1007/978-981-19-3755-2_68
490 I. Seow-En et al.
parastomal herniation with preoperative stoma Indications

site marking, which the authors suggested was
a result of transrectus ostomy creation [6]. The The best remedy for parastomal hernia is to
ideal trephine size is not yet established, reverse the stoma and restore intestinal continu-
although an increased risk of herniation has ity. This option may not be always possible, as in
been associated with a defect of 3 cm and the case of an abdominoperineal resection. In our
above [7, 8]. practice, end colostomies following abdomino-
The extraperitoneal technique of end stoma perineal resections complicated by symptomatic
creation, described by Goligher in 1958, was parastomal hernias is the most common indica-
devised to reduce small bowel internal herniation for surgery. Patients with bothersome symp-
tion into the lateral peritoneal space [9]. This toms, cosmetic concerns, or emergency
method was also found in a 2016 meta-analysis indications should undergo surgical intervention.
to have a significantly lower rate of parastomal Based on current evidence no recommendation
herniation compared to the transperitoneal can be made for operative repair over regular
approach (6% vs 18%) as well as stomal pro- observation for asymptomatic patients or those
lapse rate (1% vs 7%) [10]. Similar benefits with mild complaints [14]. Support garments
were reported with the “Goligher method” fol- may improve some symptoms.
lowing a laparoscopic approach to bowel resec-
tion and stoma formation [11]. Many recent
studies have also evaluated the utility of prophy- Surgical Approach
lactic mesh placement, either biologic or syn-
thetic, at the time of permanent ostomy creation. Options for surgical repair of parastomal hernias
A 2018 Cochrane meta-analysis of 10 random- include local suture repair, stoma relocation, and
ized controlled trials with 944 patients looked at various forms of mesh repair. Suture repair is the
mesh placement for prevention of parastomal easiest method and avoids a repeat laparotomy or
herniation [12]. Seven of these trials described laparoscopy. After parastomal incision and her-
an open sublay and three a laparoscopic intra- nia sac reduction, the fascial opening is narrowed
peritoneal onlay method, of which the most using absorbable or nonabsorbable sutures. Of all
recent [13] employed a laparoscopic modified methods, direct suture repair has the highest rate
Sugarbaker technique. The authors found that of hernia recurrence ranging from 46 to 100%
using a prophylactic mesh halved the incidence [2], with an overall morbidity and infection rate
of hernia (41% vs. 22%) without increasing of 23% and 12%, respectively [15]. Despite this,
stoma-related infection rates, although the over- direct repair may have a role in selected emer-
all quality of evidence was low due to a high gency cases or frail patients who are unable to
degree of clinical heterogeneity [12]. The 2018 tolerate more major surgery. Stoma relocation
European Hernia Society guidelines strongly involves resiting the stoma to a new position on
recommend the use of a prophylactic nonab- the abdominal wall. While this has a lower recur-
sorbable mesh upon the construction of an end rence rate (0–76%) than direct tissue repair [2], it
colostomy [14]. is inferior to mesh repair and should only be used
The transrectus, transperitoneal route without if the existing stoma site is unsatisfactory.
the use of mesh prophylaxis is still a popular Mesh repair can be onlay (fixation onto the
approach for end ostomy creation, and parasto- fascia of the anterior rectus sheath and aponeuro-
mal herniation remains a common complication. sis of the external oblique muscle), retromuscular
There are several different approaches to surgical sublay (dorsal to the rectus muscle and anterior to
repair of parastomal hernias. In this chapter, we the posterior rectus sheath), or intraperitoneal
evaluate the various methods with a focus on (intra-abdominal fixation onto the peritoneum)
laparoscopic repair. [14]. Two common methods are used for intra-
Laparoscopic Parastomal Hernia Repair 491
peritoneal prosthesis placement, the Sugarbaker

technique, first described in 1985 [16], and the
keyhole technique. A third method, the sandwich
technique, involves a combination of both meth-
ods and uses two meshes. In a 2012 review, recur-
rence rates for mesh repair ranged from 7 to 17%
and did not differ significantly between the dif- Assistant
ferent methods when open surgery was per-
formed [15]. Overall morbidity and mesh
Surgeon
infection rates were low and comparable for each
type of mesh repair.
Perhaps the success of laparoscopy for ven-
Nurse
tral hernia repair has led to an increased uptake
of the laparoscopic modality for parastomal her-
nia repair [17], with both having similar short-
term outcomes [18]. A 2013 retrospective
review of more than 2000 patients, of which
Fig. 1 Schematic of the operating setup and port placement
10% were performed by laparoscopy, showed for repair of a right lower quadrant parastomal hernia. The
that the minimally invasive approach was asso- 12 mm camera port can be placed at either of the two supe-
ciated with a shorter operating time, decreased rior “x” markings with 5 mm ports placed at the other two
length of hospital stay, lower risk of morbidity,
and lower risk of surgical site infection, follow-
ing adjustment for all potential confounders
including age, gender, ASA score, emergency or
elective surgery, hernia type, and wound class
[19]. Interestingly, while the intraperitoneal
mesh techniques have similar recurrence rates
when performed via open surgery, using lapa-
roscopy the same meta-analysis reported the
modified Sugarbaker approach having a signifi-
cantly lower recurrence rate than the keyhole
method [15]. Moreover, the laparoscopic sand-
wich method showed promising initial results Fig. 2 Fascial defect and proximal bowel limb clearly
[20] but requires further evaluation before rou- seen following reduction of hernia sac and adequate
tine use can be recommended [14]. adhesiolysis
OT Setup Surgical Technique
Schematic of the operating setup and port posi- Essential steps and technique
tioning for repair of parastomal herniation of an 1. Adhesiolysis
end colostomy following abdominoperineal 2. Reduction of the hernia sac contents
resection is shown in Fig. 1. The patient is placed 3. Placement and fixation of the prosthesis
supine. A 12 mm camera trocar is placed under
direct vision at the right flank to avoid adhesions Following laparoscopic entry, adequate adhe-
from previous midline surgery. Two 5 mm work- siolysis and careful reduction of hernia sac con-
ing trocars are placed at the right abdomen. tents are performed as per usual. The fascial defect
Prophylactic intravenous antibiotics are given at should be clearly seen by the end of this process
anesthetic induction. (Fig. 2). The keyhole technique uses a slit mesh
with a 2–3 cm “keyhole” cut-out to allow passage nally. Appropriate mesh size is selected such that
of the bowel while covering the entire fascial the fascial defect can be overlapped by 4–5 cm cir-
defect. There is a risk of bowel obstruction if too cumferentially after fixation [22]. A larger mesh
small a keyhole is made and risk of hernia recur- can be chosen and trimmed if necessary. A length
rence if the keyhole is too large. The Sugarbaker of Prolene 2–0 suture with a straight needle is
technique is more easily accomplished by securing anchored to the anticipated cranial end and another
a piece of non-slit mesh over the entire fascial similar length anchored to the lateral aspect of the
defect. We favor the latter technique, for its rela- mesh, both on the synthetic side. The mesh is then
tive simplicity and lower recurrence rates. tightly rolled up along with the attached straight
In the Modified Sugarbaker method, the proxi- needles and introduced into the abdomen through
mal bowel is anchored using Ethibond 2–0 to the the 12 mm trocar.
peritoneum lateral to the hernial defect at two Within the peritoneal cavity, the mesh can be
points (Fig. 3). The fascial defect can be accurately unfurled and positioned with the synthetic sur-
measured using a ruler (Fig. 4) to assist in prepara- face facing up. The straight needles are passed
tion of the mesh. We use a Bard™ Composix™ through the anterior abdominal wall at the corre-
E/X mesh, which is comprised of a synthetic layer sponding superior and lateral positions adjacent
of polypropylene, combined with a permanent to the hernia defect (Fig. 5). The sutures are held
barrier layer of expanded polytetrafluoroethylene with clamps and held taut; this two-point tempo-
(ePTFE) [21]. The mesh is first prepared exter- rary fixation to the abdominal wall spreads the
Fig. 3 The bowel limb is secured on either side to the peritoneum just lateral to the fascia defect
Fig. 4 The fascia defect is accurately measured to assist in mesh preparation

Fig. 5 Prolene 2/0 with straight needles are anchored to the mesh and passed through the anterior abdominal wall at
the 12 and 3 o’clock positions
The choice of mesh is an important consider-

ation. Synthetic uncoated meshes, such as poly-
propylene, should not be used for intraperitoneal
repair as they are associated with a significant
risk of adhesions and mesh erosion [15, 23].
Biologic meshes have been shown to have high
recurrence rates of 16–90% [24]. Composite
prostheses are the ideal design for intraperitoneal
hernia repair as these meshes comprise of a per-
manent synthetic material for the parietal side to
encourage adhesion formation and an adhesion
barrier layer for contact with the visceral side
[21]. The adhesion barriers can either be absorb-
Fig. 6 Once the trans-fascial sutures are held taut, the
able or permanent. Thus far, ePTFE mesh has
mesh can be appropriately positioned to facilitate subse- been the popular choice for laparoscopic
quent fixation Sugarbaker repair [17]. The advantage of ePTFE
is the microporous structure which prevents tis-
mesh out over its intended position to facilitate sue ingrowth into the prosthesis, with a low ten-
tacking (Fig. 6). Next, the mesh is secured using dency for developing adhesions [25].
a ProTack™ Fixation Device in a double crown Surgeons should also be aware of mesh
fashion (Fig. 7) just beyond the fascial defect and shrinkage over time. Shrinkage of the mesh and
a second layer at the outer periphery of the mesh. enlargement of the central hole is likely the
While applying the tacks laterally it is important greatest contributing factor to the higher
not to injure the bowel. A reasonable amount of reported recurrence rate of the keyhole method
space is left to accommodate passage of stool compared to the Sugarbaker technique [15]. It
through the lateralized bowel “mesh flap valve.” is therefore essential to achieve good mesh
The trans-fascial Prolene 2–0 sutures can be cut positioning and adequate fascial overlap of the
externally, and the surgery is concluded. mesh circumferentially.
Fig. 7 The mesh is secured using the double crown method. (left) The outer layer of tacks is applied leaving adequate
space for the lateralized bowel. (right) The inner layer of tacks applied just beyond the fascial defect

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H, Yamakawa Y, Numata M, Furutani A, Suzuki T, 18. Levy S, Plymale MA, Miller MT, Davenport DL,
Torii K. Relationship between stoma creation route Roth JS. Laparoscopic parastomal hernia repair: No
for end colostomy and parastomal hernia devel- different than a laparoscopic ventral hernia repair?
opment after laparoscopic surgery. Surg Endosc. Surg Endosc. 2016;30(4):1542–6.
2017;31(4):1966–73. 19. Halabi WJ, Jafari MD, Carmichael JC, Nguyen
12. Jones HG, Rees M, Aboumarzouk OM, Brown J, VQ, Mills S, Phelan M, Stamos MJ, Pigazzi
Cragg J, Billings P, Carter B, Chandran P. Prosthetic A. Laparoscopic versus open repair of parastomal
mesh placement for the prevention of parasto- hernias: an ACS-NSQIP analysis of short-term out-
mal herniation. Cochrane Database Syst Rev. comes. Surg Endosc. 2013;27(11):4067–72.
2018;7(7):CD008905. 20. Berger D, Bientzle M. Polyvinylidene fluoride: a suit-
13. López-Cano M, Serra-Aracil X, Mora L, Sánchez- able mesh material for laparoscopic incisional and
García JL, Jiménez-Gómez LM, Martí M, Vallribera parastomal hernia repair! A prospective, observational
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S, Espín E, Navarro-Soto S, Armengol-Carrasco 21. Deeken CR, Faucher KM, Matthews BD. A review of
M. Preventing Parastomal Hernia Using a Modified the composition, characteristics, and effectiveness of
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A Randomized Controlled Trial. Ann Surg. 22. Hansson BME, Morales-Conde S, Mussack T,
2016;264(6):923–8. Valdes J, Muysoms FE, Bleichrodt RP. The lapa-
14. Antoniou SA, Agresta F, Alamino JMG, Berger roscopic modified Sugarbaker technique is safe
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Part XX
Colorectal Surgery
Laparoscopic Right
Hemicolectomy with Complete
Mesocolic Excision and Central
Vascular Ligation (CME/CVL)
for Right Sided Colon Cancer
Ming Li Leonard Ho and William Tzu-Liang Chen
Introduction (with Clinical Data) Contraindications
Hohenberger et al. [1] advocated CME/CVL for Patients with distant metastases should not be
resection of right-sided colon cancers. CME considered for this operation. Cancers related to
involves sharp dissection along Toldt’s fascia hereditary syndromes such as familial adenoma-
with the goal of removing the primary tumor, its tous polyposis (FAP) or Lynch syndrome are
mesentery, and an undisrupted envelope of meso- contraindicated as well. Other contraindications
colic fascia. The specimen would contain adja- to the operation include obstructed or perforated
cent blood vessels, draining lymphatics, and tumors, previous abdominal surgery, or comor-
neural tissue, which are potential pathways bidities (such as severe heart or lung disease) that
through which the tumor may spread. The second render the patient unfit for laparoscopic surgery.
component is CVL whereby the tumor-supplying
vessels are ligated at their origin. This ensures the
maximal harvest of all regional lymph nodes. Preoperative Assessment
CME/CVL for right-sided colon cancer has
been shown to result in reduced local recurrence A colonoscopy is done to biopsy the tumor as
[1], higher lymph node yield [2], and improved well as to confirm its location. The tumor is tat-
disease–free survival [3]. tooed routinely. Computed tomography (CT) of
the thorax, abdomen, and pelvis is performed to
assess for metastatic disease. Bowel preparation
Indications is not routinely ordered. A routine anesthetic
assessment is performed prior to the surgery.
Adenocarcinoma is located from the cecum to
the mid-transverse colon with pre-op staging of
cT3–4 or N1–2. OT Setup
The patient is placed in a modified Lloyd Davis

position with both arms tucked in. The surgeon
stands between the patient’s legs while the cam-
M. L. L. Ho · W. T.-L. Chen (*) era assistant is positioned on the right of the sur-
Surgery, China Medical University Hsinchu Hospital, geon. If a surgical assistant is available, he/she
Zhubei City, Hsinchu County, Taiwan will stand on the surgeons’ left. Refer to Fig. 1
e-mail: wtchen@mail.cmuh.org.tw for OT setup.
https://doi.org/10.1007/978-981-19-3755-2_69
500 M. L. L. Ho and W. T.-L. Chen
Assistant
Cameraman 12
Nurse
5
Surgeon
12
Fig. 1 OT setup
Surgical Technique
Port Placement: The camera port is usually

inserted supra or infra umbilically. A 12 mm port
is inserted 2 cm superior to the pubic symphysis
at the midline while a 5 mm port is inserted at the
right iliac fossa. An additional 5 mm port may be
inserted at the right hypochondrial region for the
assistant. Refer to Fig. 2.
Colon mobilization: Pneumoperitoneum is
created at 10–15 mm Hg. The abdominal cavity
is inspected for metastases. Once the patient is
positioned in a Trendelenburg position with the
left side down, the omentum, small bowel, and Fig. 3 Tenting the terminal ileum mesentery and mobili-
zation of the retroperitoneum using monopolar cautery
transverse colon are swept to a cephalad direc-
tion. The terminal ileum is lifted anteriorly
towards the abdominal wall (refer to Fig. 3), subsequently dissect anterior to it. In the author’s
exposing the cleavage plane between ileal mes- practice, the medial extent of dissection is
entery and retroperitoneum. Peritoneum overly- reached when the duodenum and pancreatic head
ing this plane is scored with either monopolar are exposed (refer to Fig. 4). Further mobilization
diathermy or an advanced energy device. As dis- is performed in towards the direction of
section proceeds along Toldt’s fascia, the ileal Morrisons’ pouch until the dissection plane is
mesentery, and posterior aspect of the right colon separated from Morrisons’ pouch by a layer of
are mobilized off the retroperitoneum. The peritoneum. A gauze is placed at the dissected
authors routinely leave the lateral attachments of area to demarcate the dissected plane.
the colon untouched, as this helps to provide CVL: Prior to commencing the CVL, the mes-
additional counter traction. entery of the ascending and transverse colon is
During dissection in the superior direction, it spread out to visualize the location of the ileoco-
is important to look out for the duodenum and lic (IC), middle colic (MC), and superior
Laparoscopic Right Hemicolectomy with Complete Mesocolic Excision and Central Vascular Ligation… 501
Fig. 4 At the medial extent of mobilization, the duode- Fig. 5 Ileocolic artery and vein (arrowed) take-off from
num and pancreatic head are exposed SM pedicle
esenteric (SM) pedicles. The peritoneum over-

m
lying the pedicles is scored. Next, the terminal
ileum is located and the proximal transection
point is decided. Using an energy device, a mes-
enteric window is created adjacent to the proxi-
mal transection point. A laparoscopic stapler is
introduced through this window to transect the
ileum. The ileal mesentery is divided using
energy device in the direction of the SMA
pedicle.
At the junction of the IC and SM pedicles, fine
dissection is performed to skeletonize the vessels
and demonstrate the take-off of the IC from the
SM vessels (refer to Figs. 5 and 6). Failure to Fig. 6 Middle colic artery (arrowed) branching off from
SMA
demonstrate this could lead to inadvertent liga-
tion of the SM vessels, resulting in excessive
small bowel ischemia. In the event that initial ligated for mid-transverse colon tumors. The gas-
vessel identification is in question, it is advised trocolic trunk is usually identified and preserved.
that dissection continues along the SM pedicle in Once this is done, the CVL is completed. A lapa-
the cephalad direction; dissected vessels subse- roscopic stapler is used to transect the transverse
quently arising from the SM pedicle will provide colon at the intended distal transection point.
more information on vascular anatomy. (Fig. 7).
After ligation of the IC pedicle, the next vessel Anastomosis: This can be performed in the iso
to be ligated is the right colic artery should it be or antiperistaltic fashion. Using diathermy, an
present. Approximate location of the middle colic opening is made in the ileum/colon immediately
(MC) pedicle can be located via inspection of the beyond the staple line at the anti-mesenteric sur-
transverse colonic mesentery. For tumors located face. A 60 mm laparoscopic stapler is inserted
between the cecum and the proximal transverse into the bowel lumen to form the anastomosis.
colon, the right branch of MC vessels is ligated. The anastomosis is subsequently closed using
The main MC vessels are dissected free and sutures (either vicryl 3/0 or V—lock) or stapler.
Fig. 7 Post CVL, the SMV is exposed. The SMA is not

dissected free as lymph node metastasis tends not to Fig. 9 Closure of the anastomosis using stapler
spread beyond the SMV. Leaving the SMA undissected
also results in better function
Fig. 10 The completed anastomosis

Fig. 8 Forming the intracorporeal antiperistaltic ileocolic
anastomosis using a laparoscopic stapler
(a) Misidentification of critical vessels. While
performing CVL, it is important to dissect
Alternatively, if the bowel ends are sufficiently the right colonic vessels adequately and
mobile, they can be exteriorized via a mini mid- demonstrate their take-off from the SM ped-
line laparotomy wound and anastomosed in the icle prior to ligation. Clear demonstration of
usual fashion as per open surgery. After the anas- vascular anatomy is a critical step in prevent-
tomosis is done, the remaining peritoneal attaching a catastrophic ligation of the SM
ments of the right colon are divided and the pedicle.
specimen is retrieved through a Pfannenstiel (b) Injury to SM vessels. Excessive counter
wound. The authors routinely place a drain adja- traction, for example, from an inexperienced
cent to the anastomosis (Figs. 8, 9, and 10). assistant tenting up tissues during CVL, may
result in avulsion of the SM pedicle or its
branches. The authors address this issue by
Complications and Management routinely performing the operation without a
surgical assistant. This means that counter
The authors wish to highlight certain complica- traction is solely provided by the surgeon
tions and pitfalls specific to the operation. and makes it less likely for unintended tissue
Laparoscopic Right Hemicolectomy with Complete Mesocolic Excision and Central Vascular Ligation… 503
avulsion or trauma to happen. Also, by keep- the mesentery containing the SM branches is
ing the right colon’s lateral attachments not attached to the pancreas or duodenum.
untouched till the specimen is ready to be While performing CVL around this area, the
extracted provides an additional degree of chances of injuring small vessels around the
counter traction for the surgeon. However, in pancreas or duodenum, or even direct injury
situations such as patients with copious vis- to these organs, is hence minimized if the
ceral fat, the availability of another assistant mesentery is well mobilized.
is a significant benefit. When bleeding (d) Intracorporeal anastomosis. Performing anas-
occurs around the SM pedicle region, it is tomosis this way has several advantages.
imperative to (a) stop the bleeding, (b) assess Firstly, the surgeon will be able to avoid unnec-
where the bleeding is arising from, and (c) essary traction onto the transverse colon when
ensure the integrity of the SM vessels. For delivering it through a midline mini-laparot-
(a), initial compression using gauze com- omy wound. This is particularly relevant in
bined with the use of an effective suction obese patients as well as those with shortened
device to remove surrounding blood is use- transverse colon mesenteries. An intracorpo-
ful in stopping/slowing bleeding as well as real anastomosis provides the surgeon with
maintaining clear visualization of the surgi- superior visualization of the small bowel ori-
cal field. For additional hemostasis, adjuncts entation prior to performing the anastomosis,
like surgicel may be considered. The 5 mm mitigating the risk of small bowel torsion.
port in the right iliac fossa may be converted Next, the surgeon has the option of extracting
into a 12 mm port which can be used to the tumor via a Pfannenstiel wound, which has
facilitate gauze insertion. In (b) and (c), the clearly defined benefits over a midline wound
surgeon should dissect carefully around the in terms of incisional hernia and infection
SM region to ascertain the exact point of rates. A Pfannenstiel wound also provides
bleeding. Most of the time, bleeding is from improved cosmesis.
avulsion of small blood vessels contained
within surrounding mesenteric tissues and On the other hand, this technique has its prob-
will stop after a period of compression. lems. It requires a learning curve and is usually
Should bleeding from the main superior more time-consuming. When the ileotomy and
mesenteric vessels be confirmed or persis- colotomy are created, there is a potential for
tent bleeding which does not stop despite the bowel content to leak out into the peritoneal cav-
aforementioned maneuvers, the authors ity and result in contamination. As such, prior to
advise calling for help from another sur- making the ileotomy/colotomy, the authors rou-
geon. If there is injury to the main SM ves- tinely place chlorhexidine gauzes in the perito-
sels, recommendation is for conversion to neal cavity in advance. After creating the opening
open and urgent on-table referral to a vascu- in the bowel, should there be bowel content leak-
lar surgeon for repair. Persisting with lapa- ing out, it can be quickly wiped away using the
roscopic repair is futile unless skilled gauzes. After completing the anastomosis, the
expertise is available. surgeons routinely place all gauzes in a laparo-
(c) Injury to duodenum and pancreas. Prior to scopic bag which is subsequently extracted. An
commencing CVL, it is necessary to achieve intracorporeal anastomosis also poses technical
adequate medial mobilization of the right difficulty as it requires the surgeon to close the
colonic mesentery. The authors’ extent of anastomosis via suturing. The authors mitigate
medial dissection is when the pancreatic this by using the laparoscopic stapler for anasto-
head and duodenum are exposed. Such an mosis closure.
extensive medial mobilization ensures that
Postoperative Care tion–technical notes and outcome. Color Dis.

2009;11(4):354–64.
2. West NP, Hohenberger W, Weber K, Perrakis A, Finan
The nasogastric tube is removed immediately PJ, Quirke P. Complete mesocolic excision with central
after the operation. Once awake, the patient is vascular ligation produces an oncologically superior
allowed oral fluids ad libitum and progressed to specimen compared with standard surgery for carci-
noma of the colon. J Clin Oncol. 2010;28(2):272–8.
an oral diet from the first postoperative day. The 3. Bertelsen CA, Neuenschwander AU, Jansen JE,
urine catheter is removed on the first postopera- Wilhelmsen M, Kirkegaard-Klitbo A, Tenma JR, et al.
tive day and the drain is removed prior to dis- Disease-free survival after complete mesocolic exci-
charge. Average length of hospital stay is 5 days. sion compared with conventional colon cancer sur-
gery: a retrospective, population-based study. Lancet
Oncol. 2015;16(2):161–8.
References
1. Hohenberger W, Weber K, Matzel K, Papadopoulos
T, Merkel S. Standardized surgery for colonic can-
cer: complete mesocolic excision and central liga-
Laparoscopic Left Hemicolectomy
Ming-Yin Shen, Yeen Chin Leow,

Introduction verse colon up to the sigmoid-descending junc-

tion, it should be considered as a left segmentary
What is the clear definition of left colectomy? colectomy [2].
Unfortunately, the answer is not as clear as it is The question of whether extended right colec-
with a right colectomy. The resection can involve tomy (ERC) or LC should be more strongly indi-
resection of the colonic segment anywhere cated for the tumors involving the left transverse
between the left transverse colon and the upper colon or splenic flexure remains open. The rate of
rectum. For tumors involving the left transverse R0 resection as well as long-term oncological
colon or splenic flexure, left hemicolectomy (LC) outcomes are not different between ERC and RC
is the preferred operation. A LC is considered to [2–4]. Nevertheless, the concept has been pro-
be a resection of the mid-transverse colon to the posed that synchronous liver metastases are asso-
descending/sigmoid junction. In complete meso- ciated with the risk of distal positive lymph
colic excision (CME) and central vascular liga- nodes, and ERC should be considered for meta-
tion (CVL) for left transverse colon or splenic static patients suitable for curative treatment to
flexure colon cancer, ligation of the inferior mes- ensure R0 resection of both tumor sites [5].
enteric vein (IMV), left branch of the middle The attempts at an anastomosis of LC may be
colic artery (lt-MCA), and left colic artery (LCA) difficult because of inadequate length and ten-
at the root must be considered [1]. For resection sion. Under these circumstances, total or subto-
of mid- or distal descending colon tumors, the tal colectomy is a reasonable alternative. The
oncological resection requires division of the inverted right colonic transposition (the so-called
inferior mesenteric artery at its origin. If the Deloyers procedure) and trans-mesenteric
resection carried out involved the distal trans- colorectal anastomosis represent another alter-
native [6].
M.-Y. Shen · W. T.-L. Chen (*) Minimal invasive approaches to colon and
Division of Colorectal Surgery, Department of rectal resection have resulted in earlier tolerance
Surgery, China Medical University Hsinchu Hospital, of diet, accelerated return of bowel function,
Zhubei City, Hsinchu County, Taiwan
e-mail: wtchen@mail.cmuh.org.tw lower analgesia requirement, and shorter length
of hospital stay. Large multicentre randomized
Y. C. Leow
Colorectal Surgery Unit, Department of Surgery, trials have shown comparable disease-free and
Hospital Sultanah Bahiyah, Alor Star, Malaysia overall survival between open and laparoscopic
Division of Colorectal Surgery, Department of approaches for colon cancer [7–9]. However, all
Surgery, China Medical University Hospital, these studies exclude patients with transverse
Taichung, Taiwan colon and splenic flexure lesions, probably
https://doi.org/10.1007/978-981-19-3755-2_70
506 M.-Y. Shen et al.
because of technical difficulties specific to this colectomy. Phlegmonous tissue which is usually
location or the rarity of this condition. With the encountered in severe, complicated Crohn’s dis-
improvements in surgical techniques and instru- ease or in diverticulitis may not also be resectable
ments, increasing numbers of studies demon- via laparoscopy due to the tissue friability, bleed-
strated that the laparoscopic LC is a feasible, ing, and distortion anatomy that necessitates
safe, and effective procedure, as well as accept- open exposure. Severe peritoneal carcinomatosis
able short-term and oncologic long-term out- secondary to left-sided colon may also preclude
comes [2, 10, 11]. laparoscopic LC. There are no common criteria
to apply laparoscopic technique for combined
resection for T4 colon cancer. Tumor invasion
Indications into other organs is not an absolute contraindica-
tion if en bloc resection could be achieved.
The most common indication for LC is colon However, laparotomic conversion is necessary if
cancer (e.g., distal transverse colon cancer, oncologically curative resection is not achieved
splenic flexure colon cancer, proximal to mid laparoscopically. Significant intraoperative hem-
descending colon cancer). Other indications orrhage, in the presence of visceral lesion, incor-
include benign conditions such as diverticulitis, rect dissection, all conditions that may affect the
trauma, segmental Crohn’s colitis, ischemic coli- outcome, are contraindications of laparoscopy
tis, polyps unresected through a colonoscopy, and the conversion is necessary.
and colonic volvulus. Diverticular disease, typi-
cally with sigmoid colon resection, may require a
LC if the descending colon is unsuitable for an Preoperative Assessment
anastomosis due to active diverticulitis or muscu-
lar hypertrophy. All patients undergoing colonic surgery should
have the same preoperative workup including
anesthetic workup regardless of the surgical
Contraindications approaches. All patients should have a complete
history and physical examination. Adjunct testing
Contraindication often depends on the surgeon’s such as blood test, additional imaging (CT scan,
level of expertise with less straightforward barium enema), or cardiopulmonary testing is
patients and diseases. Certainly, hemodynami- performed when indicated. The only special con-
cally instability or cardiopulmonary disease that sideration for laparoscopic surgery is ensuring
is severe enough to make peritoneal insufflation that the surgeon can identify the site of pathology
and Trendelenburg positioning dangerous repre- at the time of operative intervention. The loss of
sent a physiologic derangement that precludes tactile sensation in laparoscopic surgery stresses
the safe application of laparoscopy. Another rela- the importance of localizing techniques, espe-
tive contraindication includes large bowel cially for small lesions. These can be evaluated
obstruction. Depending on the degree of proxi- preoperatively by colonoscopy and tattooing of
mal intestinal dilatation present, the more limited the lesion can be performed during the colonos-
volume of unencumbered working space, cou- copy 1–2 days prior to the surgery especially for
pled with higher risk of bowel perforation during early colonic cancer which ensures the oncologi-
manipulation, may warrant an open approach. cal safe margins. It is helpful to have flexible colo-
The application of self-expanding stents in noscopy in the operating room as it may be needed
obstructed colon as a bridge to laparoscopic sur- intraoperatively to identify lesions if the location
gery could be an alternative option. Severe adhe- of the lesion remains doubtful. All elective colonic
sion due to previous surgeries pose a technical resections should follow ERAS preoperative pro-
challenge to minimally invasive surgeons which tocol. The protocols include perioperative opioid-
may render patients not suitable for laparoscopic sparing analgesia, avoidance of nasogastric tubes
Laparoscopic Left Hemicolectomy 507
and peritoneal drains, aggressive management of can be adjusted intraoperatively at the stage of
postoperative nausea and vomiting, and early oral left flexure or rectal mobilization. The procedure
feedings and ambulation. Mechanical oral bowel is usually performed with one assistant. Surgeon
preparation is not needed for elective laparoscopic will stand on the patient’s right while the camera
LC. An urinary catheter is placed at the beginning assistant on surgeon’s right. During the approach
of the procedure and is removed on the first morn- of the middle colic artery, the surgeon may stand
ing after the operation. Prophylaxis antibiotic and in between the patient’s legs. The monopolar
deep vein thrombosis (DVT) prophylaxis should device with hook, spatula, or scissor or energy-
be included. based devices are adapted for the plane dissec-
tion, depending on the surgeon’s preference. The
adaptation of energy-based devices in laparo-
OT Setup (Fig. 1a, b) scopic colon cancer surgery could reduce chyle
leakage, minimize bleeding on dissection planes,
Authors routinely placed patients in lithotomy and facilitate complete plane dissection.
position with both arms tucked and the thighs
positioned using stirrups at no more than a 10°
angle to the torso. Lithotomy allows simultane- Surgical Techniques
ous access to the abdomen and perineum for
colorectal anastomosis when using the circular Ports Placements (Fig. 2)
stapler, as well as for intraoperative colonoscopy.
It also provides additional space for a second Four trocars are placed. By open technique, Camera
assistant and an additional position for the oper- port is inserted infra or supra umbilically using a
ating surgeon when mobilizing the splenic flex- balloon trocar. Pneumoperitoneum 12–15 mmHg
ure. The patient should be fixed securely on the is created and the abdomen is inspected for find-
table because the patient’s position could be ings. A 12 mm port is placed in the right lower
changed during the operation. A beanbag is used quadrant, for the operator’s right hand. A 5 mm
to secure the patient to the table, along with rein- port is placed in the right hypochondrium for the
forcement by adhesive tapes wrapping the operator’s left hand. A second 5 mm port is placed
patient’s chest to the table. The patient’s position over the left side abdomen.
a b
Cameraman
Surgeon 1st
Nurse assistant
Fig. 1 (a) Patient positioning in Trendelenberg and right side down position. (b) Surgeon and assistants standing
position
left-sided transverse mesocolon (TM), the

posterior layer of TM is dissected along the
pancreas and spread cephalad. The middle
colic artery is identified from the superior
mesenteric artery. Then the lt-MCA is dis-
sected free and divided at the root (Fig. 3d).
The medial-to-lateral (MTL) approach to
the left mesocolon easily brings the inferior
mesenteric artery (IMA) into view. The root
of sigmoid mesentery is retracted up to create
tension on the peritoneum which is then
incised using monopolar diathermy from cau-
dal to cephalad position starting from the
sacral promontory. Pneumo-dissection might
help to open up further the embryological
plane. The mesentery of sigmoid can be
retracted away from the retroperitoneum by
performing a blunt and bloodless dissection
using monopolar or advanced energy devices.
Proper Medial-To-Lateral (MTL) dissection
Fig. 2 Port placement for LC
will not expose the left ureter, left gonadal
vessel, and psoas muscle, which are left
Operatives Details undisturbed retroperitoneally. The retracting
instrument can be inserted into the plane
1. Vascular Pedicle Isolation and Ligation between the mesentery and the retroperito-
(Fig. 3a–f) neum, lifting the mesentery toward the ante-
Patient is tilted head down 15° rior abdominal wall without grasping and
(Trendelenberg) and right side down for grav- tearing tissue. Dissection carried on cephalad
itational drag of the small bowel to the right till the root of IMA with careful identification
and omentum and transverse colon slightly to and preservation of hypogastric nerves, which
cephalad. Omentum is swept cephalad direc- control urinary and sexual function. With D3
tion and the transverse mesocolon is lifted up lymph node dissection at the IMA root
to expose the cleavage plane of the pancreas. (Fig. 3e), the left colic artery (LCA) is ligated
Incision of transverse mesocolon at the level near the origin from IMA (Fig. 3f).
below lt-MCA either by monopolar diathermy 2. Splenic Flexure Mobilization (Fig. 4a, b)
or energy device to enter the lesser sac The splenic flexure of colon is mobilized
(Fig. 3a). The Treitz ligament is dissected using medial-to-lateral approach. After the
with maximum care not to damage the jeju- procedures of central vascular ligation, the
num (Fig. 3b). The peritoneal layer medial to lessor sac has been entered through the TM
the inferior Mesenteric Vein (IMV) is incised window and the mesentery root of the left
paralleled to the vessel. The IMV is easily colon is incised. By insertion of retracting
visualized, or in case of more obese patients, instrument and tenting of mesentery of both
search for, right below the inferior margin of transverse and descending colon, the
the pancreas. The IMV is dissected free and pancreatico-colonic ligament is divided using
then divided at the level close to the inferior either monopolar diathermy or advanced
border of the pancreas (Fig. 3c). energy devices (Fig. 4a). Lifting the IMV arch
In order to perform central ligation of lt- allows furthering MTL dissection by opening
MCA with a lateral-to-medial approach to the a window between the Toldt fascia anteriorly
a b
c d
e f
Fig. 3 (a) Incision of transverse mesocolon at the level inferior border of the pancreas. (d) The lt-MCA is divided
below lt-MCA to enter the lesser sac. (b) The Treitz liga- at the root. (e) D3 lymph node dissection at the IMA root.
ment is dissected with maximum care not to damage the (f) LCA is ligated near the origin from IMA
jejunum. (c) The IMV is divided at the level close to the
and the Gerotal fascia posteriorly (Fig. 4b). If the medial approach was done ade-
The border between the two fascias, which quately, colon (descending and sigmoid) can
indicates the embryonic plane of coalescence be easily mobilized from the Toldt’s fascia.
of posterior mesocolon and retroperitoneum Gently retract the descending colon medially,
is whitish, a clear sign of correct dissection this thin Toldt’s fascia is scored and divided
plane (Fig. 4b). A tough elevation of mesoco- using monopolar diathermy and advanced
lon anteriorly toward the abdominal wall energy devices (Fig. 5a). The splenic flexure
facilitates the dissection as far as the pericolic proper can then be dissected down by dividing
gutter, and downward to the level of sacral the spleno-colic ligament (Fig. 5b). The
promontory. greater omentum is separated from the gastric
3. Mobilization of Colon (Fig. 5a–c) curvature. The gastrocolic ligament is also
a b
Fig. 4 (a) The pancreatico-colonic ligament is divided (b) Dissection between the Toldt fascia anteriorly and the
Gerotal fascia posteriorly
a b
Fig. 5 (a) Gently retract the descending colon medially, the Toldt’s fascia is divided (b) Division of the spleno-colic
ligament (c) Division of the gastrocolic ligament
divided (Fig. 5c). The sigmoid and descend- Authors prefer extracorporeal hand-sewn
ing colon is fully mobilized until it is a mid- end-to-end colo-colonic anastomosis, which
line structure. For a tension-free anastomosis, offers the advantages of tension-free anasto-
sometimes mobilization of hepatic flexure mosis, and less risk of jejunum compression
may be indicated. which results in postoperatively intestinal
4. Construction of Anastomosis and Specimen obstruction. The specimen is extracted
Extraction (Fig. 6a–e) through the umbilical port, which extended to
about 3–6 cm. To avoid contamination, a suture (Fig. 6b). Antiperistaltic SSSA is also
wound protector is used. Care to be taken feasible; however, it may run higher risk of
when extracting the colon with the lesion as tensioned anastomosis. Antiperistaltic SSSA
too much of traction can disrupt the colonic required more intestinal mobilization than
wall and marginal artery which will jeopar- isoperistaltic SSSA [12].
dize anastomosis. Excessive traction may also Extended right hemicolectomy (ERC) or
cause contamination, and in the worst sce- subtotal colectomy has significant technical
nario tumor cell seeding in colonic malignan- advantages over left colectomy, especially
cies. After division of the mesocolon, routine under the circumstances of obstructing tumors
Indocyanine Green (ICG) is used to assure of the left colon, synchronous cancers in other
good vasculature of the remaining colon segments, clinically evident diverticular dis-
before every transaction. After restoration of ease, or inadequate remaining bowel length
bowel continuity, the colon is placed back into for anastomosis. Technically, it utilizes a
the abdomen and insufflation is reestablished. highly mobile segment of the bowel, the
Closure of the mesenteric gap is recom- ileum, to transpose it toward the left colon and
mended to minimize the risk of internal perform the intracorporeal ileocolonic anasto-
herniation. mosis without tension.
Alternatively, intracorporeal colocolic Trans-mesenteric colo-colonic or colorec-
functional end-to-end anastomosis, which is tal anastomosis are feasible laparoscopically
technically a side-to-side approach, can be and allow tension-free anastomosis in patients
performed if adequate bowel is preserved in with a short proximal colonic segment after
some of the cases. The superiority of side-to- extended LH. The proximal colon is mobi-
side anastomosis compared with hand-sewn is lized as completely as possible. The gasto-
having better blood flow and wider diameter colic ligament is divided and the second
thus reducing intraluminal pressure and prox- position of duodenum is exposed. An ileal
imal ischemia. Advantage of performing mesenteric window is creased in the avascu-
intracorporeal anastomosis is avoidance of lar area between the superior mesenteric and
bowel twisting in the wrong orientation and ileocolic pedicles (Fig. 6c). Then the proxi-
avoidance of excessive traction on bowel dur- mal transverse colon is pulled through the
ing anastomosis. A totally laparoscopic mesenteric window to create a tension-free
approach represents the better treatment par- anastomosis (Fig. 6d). In most cases, division
ticularly for obese patients, as it avoids the of the middle colic vessels is necessary for
exteriorization of heavy and short mesenteries full mobilization; therefore, it is important to
through much thicker abdominal walls and preserve the marginal vessels to avoid the
the risk of microlacerations which may affect risk of ischemia after middle colic vessel
the success of the anastomosis. The intracor- ligation.
poreal transections of the transverse and If trans-mesenteric anastomosis is still not
descending colon are accomplished using feasible, the inverted right colonic transposi-
60 mm/3.5 mm blue-load articulating linear tion procedure is an alternative salvage. After
endoscopic staplers. The specimen, com- full mobilization and middle colic vessel liga-
pletely separated from all attachments, is then tion, the right colon is rotated 1800 counter-
kept aside in the abdominal cavity. The trans- clockwise around the ileocolic vessel axis
verse and the left colon are lined up side to such that the cecum is cephalad while the
side (isoperistaltic manner), and a stapled hepatic flexure is caudal (Fig. 6e). The right
side-to-side colocolic anastomosis (SSSA) is colon can easily be anastomosed tension-free
conducted with one fire of a 60 mm blue end- to the colonic or rectal stump. All patients
ostaper load (Fig. 6a). The enterotomy is undergoing the Deloyers procedure have rou-
closed using a 3–0 PDS double layer running tine appendectomy.
a b
c d
Fig. 6 (a) Isoperistaltic SSSA is conducted with one fire cles (d) The proximal transverse colon is pulled through
of a 60 mm blue endostaper load (b) The enterotomy is the mesenteric window (e) Deloyers procedure: the right
closed using a 3–0 PDS double layer running suture (c) colon is rotated 1800 counterclockwise around the ileoco-
An ileal mesenteric window is creased in the avascular lic vessel axis such that the cecum is cephalad while the
area between the superior mesenteric and ileocolic pedi- hepatic flexure is caudal
Postoperative Care the operation, the patient is given oral fluid diet
and progressed to an oral diet from the first post-
Authors follow postoperative ERAC protocol operative day as long as patients tolerate well. The
management. Postoperatively, the patients are urine catheter is removed on the next day and if
placed on an enhanced recovery pathway. The drain is inserted, the drain is removed prior to dis-
orogastric tube is removed in the operating room charge. Postoperative analgesia as per pain team.
prior to awakening from anesthesia. Following The average length of hospital stay is 3–5 days.
References 7. Clinical Outcome of Surgical Therapy Study Group,

Nelson H, Sargent DJ, et al. A comparison of lapa-
roscopically assisted and open colectomy for colon
1. Watanabe J, Ota M, Suwa Y, et al. Evaluation of
cancer. N Engl J Med. 2004;350(20):2050–9.
lymph flow patterns in splenic flexure colon cancers
8. Veldkamp R, Kuhry E, Hop WC, et al. Laparascopic
using laparoscopic real-time indocyanine green fluo-
surgery versus open surgery for colon cancer: short-
rescence imaging. Int J Color Dis. 2017;32(2):201–7.
term outcome of a randomised trial. Lancet Oncol.
2. Martínez-Pérez A, Brunetti F, Vitali GC, et al. Surgical
2005;6(7):477–84.
treatment of colon cancer of the splenic flexure: a
9. Jayne DG, Thrpe HC, Copeland J, et al. Five-year fol-
systematic review and meta-analysis. Surg Laparosc
low-up of the Medical Research Council CLASICC
Endosc Percutan Tech. 2017;27(5):318–27.
trial of laparoscopically assisted versus open surgery
3. Secco GB, Ravera G, Gasparo A, et al. Segmental
for colorectal cancer. Br J Surg. 2010;97(11):1638–45.
resection, lymph nodes dissection and sur-
10. Grieco M, Cassini D, Spoletini D, et al. Laparoscopic
vival in patients with left colon cancer. Hepato-
resection of splenic flexure colon cancers: a retrospec-
Gastroenterology. 2007;54(74):422–6.
tive multi-center study with 117 cases. Updat Surg.
4. Gravante G, Elshaer M, Parker R, et al. Extended
2019;71(2):349–57.
right hemicolectomy and left hemicolectomy for
11. Okuda J, Yamamoto M, Tanaka K, et al. Laparoscopic
colorectal cancers between the distal transverse and
resection of transverse colon cancer at splenic flex-
proximal descending colon. Ann R Coll Surg Engl.
ure: technical aspects and results. Updat Surg.
2016;98(5):303–7.
2016;68(1):71–5.
5. Manceau G, Mori A, Bardier A, et al. Lymph
12. Matsuda A, Miyashita M, Matsumoto S, et al.
node metastases in splenic flexure colon cancer:
Isoperistaltic versus antiperistaltic stapled side-to-
is subtotal colectomy warranted? J Surg Oncol.
side anastomosis for colon cancer surgery: a random-
2018;118(6):1027–33.
ized controlled trial. J Surg Res. 2015;196(1):107–12.
6. Chen YC, Fingerhut A, Shen MY, et al. Colorectal
anastomosis after laparoscopic extended left col-
ectomy: techniques and outcome. Color Dis.
2020;22(9):1189–94.
Laparoscopic Anterior Resection
Elaine Hui Been Ng, Yeen Chin Leow,

Introduction tion under direct vision and gentle continuous

traction by RJ Heald [1] heralded the major
The first radical rectal surgery was first per- milestone in modern rectal cancer surgery in sig-
formed by Sir William Ernest Miles with a per- nificantly reducing local recurrence and improv-
manent stoma in 1907 while restorative rectal ing patient outcomes. Although laparoscopic
resection was introduced in 1948 by Claude F surgery began in the 1980s, the first laparoscopic
Dixon. The evolution of using surgical staplers colonic surgery was only performed in 1991.
in 1972 by Mark Mitchell Ravitch, doubling sta- Laparoscopic rectal resection according to the
pling technique by Knight and Griffen in 1980 as principles of TME has been performed increas-
well as the development of coloanal anastomo- ingly since with a few randomized controlled
sis, intersphincteric dissection, and colonic- clinical trials (CLASICC, COLOR II, ACOSOG
pouch anal anastomosis by Parks, Larzothes, and Z6051, ALaCaRT) [2–7] demonstrating signifi-
Parc respectively between 1980 and 1986 allows cantly better postoperative pain, shorter hospital
more opportunities for restorative resections for stay, and improved quality of life with controver-
low rectal tumors. The concept of Total sial but mostly comparable short- and intermedi-
Mesorectal Excision (TME) with sharp dissec- ate-term oncological outcomes.
E. H. B. Ng
Colorectal Surgery Unit, Department of Surgery, Indications
Hospital Raja Permaisuri Bainum, Ipoh, Malaysia
Division of Colorectal Surgery, Department of The most common indication is for resection of
Surgery, China Medical University Hospital, sigmoid and rectal tumors as long as a negative
Taichung, Taiwan distal resection margin and adequate postopera-
Y. C. Leow tive anal sphincter integrity can be preserved.
Division of Colorectal Surgery, Department of Other indications include large rectal polyps not
Surgery, China Medical University Hospital, amenable to other excisional techniques, severe
Taichung, Taiwan
pelvic inflammation or infection causing refrac-
Colorectal Surgery Unit, Department of Surgery, tory rectal stricture, severe pelvic endometriosis,
Hospital Sultanah Bahiyah, Alor Star, Malaysia
salvage prostectomy for benign causes (rectovag-
W. T.-L. Chen (*) inal or rectourethral fistula) with failure of all
Surgery, China Medical University Hsinchu Hospital, other treatment modality, secondary tumor by
Zhubei City, Hsinchu County, Taiwan direct invasion, presacral tumors, and rectal
e-mail: wtchen@mail.cmuh.org.tw trauma.
https://doi.org/10.1007/978-981-19-3755-2_71
516 E. H. B. Ng et al.
Contraindications for preoperative oral antibiotics in combination

with mechanical bowel preparation [9].
Absolute contraindications are inability to
tolerate prolonged pneumoperitoneum in a
Trendelenburg position especially for patients OT Setup and Techniques
with cardiac failure or severe pulmonary dis-
ease, hemodynamic instability, or cases of com- The patient is placed in the modified lithotomy
promised oncological safety (sphincter, pelvic position with both legs on adjustable stirrups.
floor, sacral, and/or pelvic side wall invasion). Both arms are tucked in. A Trendelenburg posi-
Relative contraindications would be dependent tion is utilized to gravitationally move the omen-
on the skills of the surgeon and patient character- tum and bowels cephalad for unobstructed access
istics that may prohibit a laparoscopic approach to the pelvis. Tilting the patient to the right allows
including bulky rectal tumors requiring en bloc unhindered access to the regions of the inferior
multivisceral resection, morbid obesity, severe mesenteric artery and vein, left mesocolon, left
adhesions, pregnancy, and bowel obstruction. retroperitoneum, splenic flexure, and left colon
(Fig. 1).
The surgeon (S) stands on the right side of the
Preoperative Assessment patient with the camera assistant (C) beside the
surgeon. The first assistant (F) stands on the left
Postoperative expectations of pelvic organ func- side of the patient (Fig. 2). The monitor screens
tion including infertility and possibility of stoma (M) are placed on the left side of the patient with
must be discussed as anatomical restoration in flexible mobility between the cranial and caudal
low rectal resection may not be functionally end as required.
acceptable for certain patients because of their
lifestyle or occupation. (a) Placement of Trocars
A routine anesthetic assessment is performed We use an open technique to insert the
prior to surgery. Preexisting anal sphincter func- 12 mm trocar for the telescope at the umbili-
tion and previous trauma including perianal sur- cal region, favoring the supraumbilical posi-
gery must be elicited. Digital rectal examination tion. Additional varying number of working
is mandatory to assess the preexisting anal tone, trocars are placed under direct visualization.
sphincter integrity, distal margin of rectal tumor We use the 5-trocar technique—Fig. 3. A
focusing on proximity to the sphincters and pel- high anterior resection may not require the
vic floor muscles, and possibility of invasion to fifth port. The second port at RLQ (two
adjacent structures. A complete preoperative
colonoscopy is mandatory to exclude synchro-
nous proximal lesions and biopsy the tumor (tat-
too if small). Complete TNM staging with
appropriate locoregional imaging is necessary to
guide the optimal treatment approach. Computed
tomography (CT) is used for the assessment of
distant metastases and magnetic resonance imag-
ing (MRI) is the current gold standard for preop- c
erative T- and N-stage evaluation for rectal a b
tumors as well as assessment for invasion into
sphincters and pelvic floor [8].
Fig. 1 Patient is strapped to the table with a chest strap
Preoperative oral bowel preparation for rectal (a) and mouldable bean bag (b), both legs in adjustable
surgery has been controversial but the current stirrups (c) to prevent truncal sliding in the Trendelenburg
ASCRS recommendation for elective surgery is position with right table tilt
Laparoscopic Anterior Resection 517
Fig. 2 OT setup and port placement
a b Cranial end
Cranial end
6
3
4
2 5
Fig. 3 Placing the palm with the wrist on the symphysis pubis and fingers spread open on an insufflated abdomen (a)
can guide the positions of the trocars (b) placed on a semi-circular line with the left trocars as mirror trocars of the right
ngerbreadths anterior to the ASIS) is a

fi inspected for metastases. The sigmoid colon
12 mm access port for the endoscopic sta- is retracted anteriorly out of the pelvis.
pler. The left-sided trocars are mirror trocars Dissection begins at the level of sacral prom-
of the right. An additional sixth trocar at the ontory and continued cephalad towards the
RUQ is used to access the lesser sac and aid ligament of Treitz, anterior to the aorta. An
splenic flexure mobilization. avascular plane is created beneath the SRA
(b) Medial-to-lateral mesocolic dissection, arch to separate the left mesocolon from the
IMA division posterior retroperitoneal fascia in a medial-
Pneumoperitoneum is created at to-lateral fashion all the way to the left lateral
10–15 mm Hg and abdominal cavity is peritoneal reflection (Fig. 4). An alternative
Left Ureter
DJ flexure
Fig. 4 Medial-to-lateral dissection (arrow) with the SRA Fig. 6 IMV ligation, lateral to the ligament of Treitz,
arch being retracted anteriorly and the retroperitoneal fas- below the inferior border of the pancreas
cia and structures being swept posteriorly
the marginal artery. Transverse colon is

retracted caudally to divide the gastrocolic
ligament (Fig. 7b) to meet the dissection
plane in the lesser sac. Left colonic and
IMA
splenic flexure mobilization is completed
with the division of the remaining lateral
Aorta peritoneal attachments and splenocolic liga-
ments (Fig. 7c, d).
Alternatively, a reversed lateral-to-medial
Fig. 5 IMA ligation—clips placed proximally at the root, splenic flexure mobilization can be used to
2 cm distal to the aorta, after adequate skeletonization enter the lesser sac but it is technically more
difficult and has a higher chance of pancre-
atic injury.
lateral-to-medial approach is used if this (d) Pelvic Dissection:Total Mesorectal
approach becomes difficult, especially in Excision (TME) and Bowel Transection
obese patients. Sigmoid colon is retracted cephalad and
High ligation of the IMA requires expo- anteriorly to identify the retrorectal space.
sure of the root of the IMA and ligating it at The posterior rectal mobilization is carried
1–2 cm from the aorta. The IMA can be out with sharp dissection preferably with
divided between clips or with a linear vascu- monopolar electrocautery along the avascu-
lar stapler/vessel-sealing device—Fig. 5. lar areolar plane between the visceral and
(c) Inferior Mesenteric Vein (IMV) Division parietal endopelvic fascia while simultane-
and Access to Lesser Sac, Splenic Flexure, ously maintaining gentle continued traction
and Lateral Colonic Mobilization of the rectum anteriorly all the way to the
The dissection continues superiorly along pelvic floor (Fig. 8a, b). A tape can be used to
this avascular plane all the way to the infe- aid rectal retraction during the TME (Fig. 8c).
rior border of the pancreas and ligament of The dissection continues in the same plane
Treitz with a high IMV ligation at this posi- bilaterally (Fig. 8d, e) and anteriorly along
tion (Fig. 6). Transverse colon is then the Denonvillier’s fascia (Fig. 8f) down to
retracted anteriorly adjacent to the ligament the pelvic floor. Be wary not to injure the
of Treitz to divide the root of the transverse parasympathetic nervi erigentes (S2 to S4)
mesocolon anterior to the pancreas to enter from overzealous lateral dissection beyond
the lesser sac (Fig. 7a). Pancreaticocolic the mesorectal fascia. Coordinated planar
ligaments are divided, taking care to avoid tractions and counter tractions are needed for
a b
b
Mesocolon
Gastrocolic ligament
Stomach
Pancreas
Transverse colon
c d
Colon
Spleen
Splenic
flexure
Gerota’s fascia
Fig. 7 (a) Entering lesser sac. (b) Division of gastrocolic ligament. (c) Dividing lateral peritoneal attachment. (d)
Dividing splenocolic ligament
accurate TME dissection. The level of rectal posterior vaginal wall/prostate is retracted
transection is then confirmed by digital rectal anteriorly to avoid inclusion into the sta-
and/or endoscopic examination after a com- pler line. The colonic mesentery is checked
plete circumferential TME. The rectum is for twisting before firing the stapler. The
irrigated, stapled, and divided with an endo- integrity of the anastomosis is assessed
scopic stapler (Fig. 9). by visually verifying the completeness of
The mesocolon is divided intracorpore- the proximal and distal donuts, perform-
ally. A grasper holding the proximal bowel ing an air insufflation test and endoscopic
presents the specimen at the extraction site evaluation of the anastomotic stapling line.
for exteriorization (Fig. 10a). Anvil of the Several intracorporeal stapled anastomotic
circular stapler (at least 28 mm) is anchored techniques other than end-to-end anastomo-
in the conduit with a purse-string suture after sis (ETE) can be used to reduce the inci-
transection (Fig. 10b). The colon is returned dence of low anterior resection syndrome
to the abdomen and the extraction site is tem- (LARS) by creating a neorectal reservoir
porarily closed for re-pneumoperitoneum in (Fig. 11). We do not routinely insert a drain
preparation for intracorporeal anastomosis. in the pelvis. A temporary diverting stoma
(e) Anastomosis is constructed mainly in low anastomosis of
The rectal stump is transfixed with the tip immunosuppressed individuals and/or irra-
of the head of the circular stapler while the diated pelvis.
a b
Pelvic floor
“Angel hair” of the areolar plane
c d
Right lateral pelvic wall
e f Vagina
Left lateral
pelvic wall
Rectum
Fig. 8 (a) Posterior TME, sharp dissection at the avascu- cephalad; (d) right lateral TME; (e) left lateral TME; (f)
lar areolar plane; (b) complete posterior TME down to the anterior TME
pelvic floor; (c) cotton sling/tape to retract the rectum
Vagina retracted anteriorly
Fig. 9 Rectal transection with GIA, vagina retracted

anteriorly by the first assistant
a b
Fig. 10 (a) Specimen extraction. (b) Anvil inserted into the antimesenteric border of colonic conduit for side-to-end
anastomosis
colon Colonic pouch
Rectal stump
rectal stump anvil
Pelvic floor
Stapler
Fig. 11 Intracorporeal colorectal end-to-end (ETE) stapled anastomosis, side-to-end anastomosis, colonic J-pouch
Complications and Management Anastomotic Leak
Ureteric and Bladder Injury Any error during intracorporeal stapling anasto-
mosis must be fixed immediately. A close-up
Adequate exposure in the correct dissection plane visual inspection of the staple formation on the
would avoid accidental injury. Inflammation, can- rectal stump should be undertaken after the firing
cer infiltration, and adhesions can alter the regional of the endoscopic stapler and when the circular
anatomy and would require insertion of an intra- stapler is pushed up to the top of the rectal stump
operative ureteric stent for identification. Repair is before anastomosis. Any incomplete donuts
dependent on the location of injury and length of would require inspection of the anastomosis, leak
transected ureter. Bladder injury usually results from test, and additional suturing of the defect.
electrocoagulation tears during TME. Immediate Recently, the use of indocyanine green (ICG) in
suturing with postoperative bladder catheterization the evaluation of perfusion for both proximal and
for 7–10 days is usually adequate. distal stumps prior to anastomosis may reduce
the risk of anastomotic leak from ischemia [10].
A tension-free anastomosis is essential. Proximal
Vascular Injury diverting stoma should always be considered in
the presence of any doubt of the anastomotic
Aggressive grasping or lifting of the vessels during integrity.
mesenteric dissection can cause vessel tear. IMA
and IMV must be adequately skeletonized with
forceps in an alternating parallel and perpendicu- ow Anterior Resection Syndrome
L
lar direction to the vessel from its surrounding tis- (LARS)
sues at an appropriate exposure length before
vascular clipping or sealing prior to division. Alternative anastomotic techniques of STE, CJP,
Injury to the marginal artery and Arc of Riolan can and TC create a neorectal reservoir to reduce the
occur during the medial dissection into the lesser incidence of LARS, especially in young patients
sac and should be avoided to maintain collateral with irradiated pelvis. CJP has been demon-
supply to the left colonic conduit. Bleeding from strated to provide better bowel function for up to
presacral venous plexus during TME may require 2 years compared to ETE but is technically lim-
second-look laparotomy after pelvic packing if ited by a narrow pelvis, insufficient colonic
conventional hemostatic methods fail. Iatrogenic length, or colonic diverticulosis. STE seems to be
splenic injury can occur from traction or capsular functionally comparable to CJP in a limited lit-
tear during splenic flexure mobilization. erature review [11, 12].
Neurological Injury Fistula
Urinary and sexual dysfunction from damaged Although rare, rectovaginal fistula is caused
superior hypogastric plexus, the hypogastric more commonly by inadequate dissection and
nerves, the inferior hypogastric plexus, the pelvic stapling error. One must carefully dissect
splanchnic nerves, and the neurovascular bundle between the rectal stump and posterior vaginal
of Walsh from thermal injury, ischemia, tension, wall and introduce the circular stapler at a
or inflammation during IMA dissection and TME marked posterior angle in the rectal stump to
can be avoided by careful sharp dissection with avoid the inclusion of the vaginal wall in the tis-
anatomical familiarization in these areas. sue rings (donuts).
Incisional Hernia 4. Fleshman J, Branda M, Sargent DJ, Boller AM, George

V, Abbas M, et al. Effect of laparoscopic-assisted
resection vs open resection of stage II or III rectal
Specimen extraction from the conventional left cancer on pathologic outcomes: the ACOSOG Z6051
iliac fossa port or midline contributes to a higher randomized clinical trial. JAMA. 2015;314:1346–55.
incidence of incisional hernia. Moving the speci- 5. Stevenson AR, Solomon MJ, Lumley JW, et al.
Effect of laparoscopic assisted resection vs open
men extraction site to a Pfannenstiel incision resection on pathological outcomes in rectal can-
reduces the incidence [13]. cer: the ALaCaRT randomized clinical trial. JAMA.
2015;314(13):1356–63.
6. Stevenson ARL, Solomon MJ, Brown CSB, et al.
Disease free survival and local recurrence after lap-
Postoperative Care aroscopic assisted resection or open resection for
rectal cancer: the Australasian laparoscopic cancer
Nasogastric tube is removed at the end of sur- of the rectum randomized clinical trial. Ann Surg.
gery. Pelvic and peritoneal drains are not rou- 2019;269(4):596–602.
7. Fleshman J, Branda ME, Sargent DJ, et al. Disease free
tinely inserted. Postoperative urinary drainage survival and local recurrence for laparoscopic resection
should be ideally ≤24 h for low-risk patients but compared with open resection of stage II to III rectal can-
those with extensive pelvic dissection may cer: follow up results of the ACOSOG Z6051 random-
require catheterization up to 3 days after surgery. ized controlled trial. Ann Surg. 2019;269(4):589–95.
8. MERCURY Study Group. Diagnostic accuracy of
Early diet on the first day (liquids/low residue preoperative magnetic resonance imaging in predict-
diet within 4 h) after surgery should be intro- ing curative resection of rectal cancer: prospective
duced. Early postoperative mobilization is observational study. BMJ. 2006;333:779.
encouraged as early as 2 h after surgery and 6 h 9. Migaly J, Bafford AC, Francone TD, et al. The
American Society of Colon and Rectal Surgeons clin-
thereafter. ical practice guidelines for the use of bowel prepara-
tion in elective colon and Rectal surgery. Dis Colon
Rectum. 2019;62:3–8.
References 10. Gilshtein H, Yellinek S, Wexner SD. The evolving
role of indocyanine green fluorescence in the treat-
ment of low rectal cancer. ALES. 2018;3(10):1–4.
1. Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane
11. Huttner FJ, Tenckhoff S, Jensen K, et al. Meta-analysis
JK. Rectal cancer: the Basingstoke experience of
of reconstruction techniques after low anterior resec-
total mesorectal excision, 1978–1997. Arch Surg.
tion for rectal cancer. Br J Surg. 2015;102:735–45.
1998;133:894–9.
12. Brown CJ, Fenech DS, McLeod RS. Reconstruction
2. Green BL, Marshall HC, Collinson F, Quirke P,
techniques after rectal resection for rectal cancer.
Guillou P, Jayne DG, et al. Long-term follow-up
Cochrane Database Syst Rev. 2008;2008(2):CD006040.
of the medical research council CLASICC trial of
https://doi.org/10.1002/14651858.CD006040.pub2.
conventional versus laparoscopically assisted resec-
13. Samia H, Lawrence J, Nobel T, Stein S, Champagne
tion in colorectal cancer. Br J Surg. 2013;100:75–82.
BJ, et al. Extraction site location and incisional her-
3. Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van
nias after laparoscopic colorectal surgery: should we
der Pas MHGM, de ESM L-d K, COLOR II Study
be avoiding the midline? Am J Surg. 2013;205:264–7.
Group, et al. A randomized trial of laparoscopic ver-
sus open surgery for rectal cancer. N Engl J Med.
2015;372:1324–32.
Laparoscopic Abdominoperineal
Resection
Isaac Seow-En and William Tzu-Liang Chen
Introduction tionary work is still the topic of vivid discussion

more than 100 years later [3, 4]. For decades,
A rectal cancer located within the narrow con- abdominoperineal resection (APR) was the stan-
fines of the bony pelvis has for centuries been the dard treatment for all rectal cancers, until anterior
bugbear of abdominal surgeons. Advances in resection with a colorectal anastomosis was
operative technique, surgical technology, imag- reported (in 1948) to be a safe and acceptable sur-
ing methods, and multimodal therapies have dra- gical therapy for lesions located in the upper half
matically improved the prospects of this once of the rectum [5]. From the late 60s to the early
fatal disease. Despite the considerable progress, 70s, introduction of a transrectal circular stapling
cancer of the rectum remains one of the most device [6], as well as the coloanal handsewn
challenging conditions encountered by colorectal anastomotic technique [7] enabled surgeons to
surgeons in present times. perform progressively more distal rectal resec-
Perhaps the most notable contribution of the tions while preserving the anal sphincter. In 1982,
twentieth century to the management of rectal Bill Heald identified the “Holy Plane” of dissec-
cancer was that by Sir William Ernest Miles, who tion between the mesorectal and presacral fascia
described abdominoperineal excision of the rec- for total mesorectal excision (TME) [8], which
tum and anal sphincter complex with a perma- became the gold standard for oncologic resection
nent colostomy in 1908 [1]. His groundbreaking of middle to low rectal cancers.
notion of reducing recurrence by removing as Still, it was recognized that TME alone pro-
much lymphatic drainage of the rectum as possi- vided insufficient local control for more advanced
ble in a “cylindrical” concept formed the basis of disease. A major milestone came in the form of
modern rectal cancer surgery [2]. Miles’ revolu- combined chemoradiotherapy prior to surgery
[9]. For the past 20 years, neoadjuvant chemora-
diation therapy (NACRT) has been advocated for
I. Seow-En locally advanced, i.e., stage 2 and 3 cancers
Department of Colorectal Surgery, Singapore General located in the mid to distal rectum, prior to surgi-
cal resection, followed by adjuvant chemother-
Division of Colorectal Surgery, China Medical apy for nodepositive disease. 50–60% of patients
are downstaged after NACRT, with approxi-
W. T.-L. Chen (*) mately one-fifth showing a pathologic complete
Surgery, China Medical University Hsinchu Hospital, response [10]. This approach, along with
Zhubei City, Hsinchu County, Taiwan enhanced surgical techniques, has reduced the
e-mail: wtchen@mail.cmuh.org.tw local recurrence rate to 5–10% at 5 years. Next,
https://doi.org/10.1007/978-981-19-3755-2_72
526 I. Seow-En and W. T.-L. Chen
the focus turned to improving systemic control patients from 29 randomized trials compared the
[11]. Total neoadjuvant therapy, which provides classic open versus laparoscopic versus robotic
all necessary chemotherapy and radiation prior to versus transanal TME; all methods appeared to
surgery, aims to deal with circulating microme- have comparable morbidity rates and long-term
tastases earlier for better systemic control and is outcomes. However, the laparoscopic and robotic
now recognized as a valid treatment option for methods appeared to improve postoperative
locally advanced tumors [10, 12]. recovery and the open and transanal approaches
With increasing acknowledgment of the seemed to benefit oncologic resection [17].
effectiveness of adjunctive therapies, Habr- Enhanced surgical techniques in the setting of
Gama and colleagues in the mid-2000s pio- effective multimodal adjunctive therapies for low
neered the “watch-and-wait” approach on the rectal cancers have decreased the rates of APR. A
basis of an observed 26–27% rectal cancer path- pooled analysis of five large European trials sug-
ological response rate to NACRT [13]. Organ gests that the APR procedure itself was a predic-
preservation (of the rectum) thus emerged as a tor of increased local recurrence and death [18].
possible nonsurgical option in the management Compared to anterior resection, patients who
of rectal cancer [14]. A 2018 meta-analysis of 13 undergo APR also report worse body image and
cohorts showed a complete clinical response rate sexual enjoyment at 1 year postsurgery [19].
of 22.4% with a 3 year cumulative local recur- Nonetheless, APR is still the requisite procedure
rence risk of 21.6%. Most of these patients in many circumstances and remains an essential
underwent salvage surgery with a 79.1% R0 component of the armamentarium of colorectal
resection rate, 45.3% sphincter preservation rate, surgeons today. In this chapter, we will examine
and 3-year overall survival and disease-free sur- the use of the laparoscopic APR technique for
vival of 93.5 and 89.2%, respectively [15]. No low rectal cancer.
randomized trial exists and substantial deficien-
cies in our knowledge of the organ-preserving
approach prevent it from becoming mainstream Indications
therapy. Nonetheless, current evidence suggests
that the watch-and-wait may be reasonable for An individualized approach is mandatory in the
selected, including high surgical risk patients, management of patients with distal rectal cancer.
with locoregionally advanced mid to distal rectal Accurate systemic staging along with a dedicated
cancers who demonstrate complete clinical multidisciplinary team discussion should be con-
response [11]. ducted as per existing clinical guidelines [10, 20].
Surgical technique for rectal cancer has come The following should be considered when estab-
a long way since Miles’ seminal paper. The lapa- lishing the optimal surgical approach for each
roscopic approach to APR has been proven to patient:
reduce postoperative complications and hasten
recovery, without compromising oncologic out-
comes, recurrence rates, and survival [16]. Tumor Characteristics
Moreover, the advantages of laparoscopic APR
over open surgery are more pronounced than that Location of the tumor and involvement of the
of anterior resection as only small port scars anal sphincters can be determined by a digital
remain without the need for abdominal specimen rectal examination. Fixed tumors with sphincter
extraction. Robotic surgery and transanal total or levator muscle invasion will necessitate an
mesorectal excision are two newer methods that APR. Involvement of the prostate or anterior wall
have been the focus of both retrospective research of the vagina may require pelvic exenteration.
and prospective trials in recent years. A 2019 Magnetic resonance imaging (MRI) of the pelvis
meta-analysis by Simillis et al. involving 6237 using a specific rectal cancer protocol is the
Laparoscopic Abdominoperineal Resection 527
modality of choice for locoregional staging. The neoadjuvant therapy. If available, objective mea-
MERCURY trial showed that MRI can predict surement using anal manometric studies can be
surgical resectability, overall survival, and local performed. For borderline cases, it is important to
recurrence through assessment of the MRI tumor consider the high prevalence (of approximately
regression grade [21]. The utility of endorectal 40%) and long-term persistence of bowel dys-
ultrasound is limited to the differentiation of T1 function, the so-called low anterior resection syn-
and T2 tumors, the former of which may be ame- drome (LARS), following sphincter-sparing
nable to local excisional procedures in the rectal surgery [25–27]. Patients with severe
absence of high-risk MRI features. Locally LARS symptoms may prefer a permanent stoma
advanced low rectal cancers should be referred and would have benefited from an upfront
for neoadjuvant radiation. We use a long course APR. This possibility should be emphasized pre-
protocol of 45–50.4 Gy in 25–28 doses given in operatively to patients who are at higher risk for
conjunction with chemotherapy, typically LARS, including those with a history of radio-
5-FU. Surgery may be performed between 5 and therapy or in whom anterior resection would
12 weeks following full dose 5.5 weeks NACRT result in a low anastomotic height [26]. Overall
[10], although the ideal timing remains the sub- functional status should also be taken into
ject of controversy [20]. Posttreatment MRI is account.
important to assess response and can be per-
formed at the mid-way point between the end of
treatment and intended timing of surgical Preoperative Preparation
resection.
Sphincter preservation may become possible Ostomy nurse counseling and stoma site selec-
in cases where initial tumor bulk prevented con- tion for optimal positioning of the permanent
sideration of such surgery and the extent of the colostomy are important to facilitate postop-
tumor is improved after neoadjuvant therapy. An erative stoma care and function. The patient
APR is indicated where an R0 resection of the should be enrolled in an enhanced recovery
tumor would result in loss of anal sphincter func- after surgery (ERAS) program. We do not
tion and incontinence [10]. The acceptable distal advocate mechanical bowel preparation before
resection margin for low rectal cancers should be APR. Prophylactic intravenous antibiotics are
greater than 1 cm, although a < 1 cm margin has given at anesthetic induction and throughout
been shown not to compromise oncologic safety the duration of surgery. Pharmacological or
in selected patients [22]. Intersphincteric resec- mechanical venous thromboembolism prophy-
tion for very low locally advanced rectal cancer laxis should be instituted due to the high-risk
has also been found to have acceptable oncologic nature of this surgery. The ureters can be stented
outcomes [23]. prior to rectal resection to facilitate intraopera-
tive identification, which may be advantageous
in difficult cases with previous pelvic surgery. A
Sphincter Function urinary catheter must be inserted.
A thorough history and physical examination can

determine the pretreatment baseline function. It OT Setup
would be pointless exercise to preserve a poorly
functioning anal sphincter. A meta-analysis of 25 Abdominal Phase
studies with 6548 patients demonstrated that
NACRT negatively affected long-term anorectal Our patient position prior to draping can be seen
function after surgery [24]. It is therefore advis- in Fig. 1. The patient is placed in the modified
able to repeat functional assessment following Lloyd-Davis position with the lower limbs in
Fig. 1 APR abdominal phase standard positioning before

draping
foot stirrups and the buttocks a few centimeters

off the caudal edge of the operating table. Both
arms are tucked in to facilitate positioning of the
surgeon, camera operator, and assistant. A small Fig. 2 The ideal position of the lower limbs during
sandbag (or folded drapes) is placed below the surgery
sacrum to elevate the pelvis, enabling better
visualization of the deep pelvic structures dur- the right iliac fossa trocar and the umbilical tro-
ing surgery. A steep Trendelenburg position is car. In our experience, this port position provides
maintained for most of the abdominal phase. To the best ergonomics for deep pelvic dissection.
stabilize the patient’s position, we use fixed The assistant ports are a right-to-left mirror
shoulder supports to absorb the patient’s weight, image of the working ports, using two 5 mm tro-
with soft gel pads minimizing the risk of pres- cars. One assistant trocar can be placed at the
sure injury. To provide additional support, a intended (and preoperatively marked) colostomy
strip of strong adhesive tape is used to strap the site to minimize operative incisions. A single
patient’s chest, just above the nipple line, to the assistant trocar may be sufficient in straightfor-
sides of the table. Alternatively, an adjustable ward cases.
“bean bag” above a soft gel layer can be molded
around the patient to prevent sliding. We use a
soft elastic bandage, wrapped tightly around the Perineal Phase
lower limb, as a substitute for compression
stockings. The lower limbs should be in a Upon completion of the abdominal phase, the
relaxed posture with the knees flexed at 45° to patient is transferred to a trolley and the oper-
prevent overstretching of the peripheral nerves ating table is prepared for the prone jackknife
(Fig. 2). (Kraske) position as shown in Fig. 4. The leg
Operating setup and ports are shown in Fig. 3. boards are reattached. A donut head pad is
A 12 mm camera trocar is placed via an umbili- used for facial support. It is necessary to pro-
cal incision under direct vision. Working trocars vide adequate padding for the colostomy and
consist of a 12 mm trocar placed two finger- drain site while the patient is prone to prevent
breadths medial to the right anterior superior pressure injury. The knees are kept in slight
iliac spine and a 5 mm trocar midway between flexion on a separate cushioned cardiac trolley
Camera man
Assistant
Surgeon
Nurse
Fig. 3 (Above) Schematic of operating setup and port placement for laparoscopic APR. (Below) Left-sided assistant
trocar can be placed at the intended end colostomy site
(Fig. 5), to prevent stretch of the lower limb

nerves.
Adhesive tape is used to splay the buttocks
apart and anchored to the table frame on each
side (Fig. 6). The anus is sutured shut to prevent
leakage of stool during the procedure. For the
perineal skin incision, the posterior extent should
be midway between the tip of the coccyx and the
anus, the anterior extent at the perineal body, and
the lateral extent midway between the ischial
tuberosities and the anus. Operative landmarks as
well as the elliptical skin incision are shown in
Fig. 4 Preparing the operating table for the prone jack- Fig. 6.
knife position
Fig. 5 The prone jackknife position for the APR perineal phase
Abdominal Phase Technique
The initial approach to the APR abdominal phase

is not unlike that for a low anterior resection (see
chapter on Anterior Resection). A splenic flexure
takedown is unnecessary, and the proximal colon
is mobilized just enough to allow the exterioriza-
tion of an end colostomy following bowel resec-
tion. TME dissection and rectal mobilization
should be progressed as distally as possible to
facilitate the subsequent perineal phase. A cotton
tape tie at rectosigmoid junction is useful to pro-
Fig. 6 Preparing the perineum for the perineal phase. The vide traction of the rectum out of the pelvis
downward arrow marks the coccygeal location and the (Fig. 7). The knot is grasped by the surgical assis-
points on either side of the anus indicate the position of tant for retraction and manipulation of the rectum
the ischial tuberosities. Using these landmarks, the skin
incision is delineated as shown during TME. For females, the uterus can be tem-
porarily hitched to the anterior abdominal wall
using a Prolene 2–0 straight needle passed
through the uterine fundus or the broad ligaments
Surgical Technique (Fig. 8). This provides visualization without the
need for traction by the assistant. Following ade-
Abdominal Phase Essential Steps quate colon and rectal mobilization, the proximal
colon is transected with an appropriate oncologic
1. Medial to lateral colonic mobilization margin using an endoscopic linear stapler. A
2. Inferior mesenteric artery ligation drain is placed in the pelvis prior to closure. The
3. Rectal mobilization pelvic floor sigmoid colon is exteriorized via a left-sided skin
4. Proximal bowel transection incision and the abdominal wounds are closed
5. End colostomy creation before the end colostomy is matured.
Fig. 7 (Above) A cotton tape is tied around the upper rec- Fig. 8 (Above) A straight needle is passed from the skin
tum. (Below) The knot is grasped by the surgical assistant through the fundus of the uterus. (Below) The uterus is
for retraction and manipulation of the rectum hitched to the anterior abdominal wall to provide better
access to the deep pelvis
Perineal Phase Essential Steps recurrence rates [28]. We favor a prone position
for APR for anteriorly based tumors for the supe-
1. Extra-sphincteric incision rior visualization of the anterior plane between the
2. Entry into abdominal cavity via anococcygeal tumor and the prostate or vagina. For cases in
ligament which the dissection is potentially difficult due to
3. Division of lateral levator attachments anatomical constraints, bulky tumors, or previous
4. Exteriorization of proximal end of the radiation, the lithotomy position allows a com-
specimen bined abdominal and perineal approach which
5. Division of the anterior attachments (to the may be useful to establish an accurate plane of dis-
prostate/vagina) section, although pneumoperitoneum will be lost
6. Wound closure (with mesh or flap reconstruc- once the abdominal cavity is entered from below.
tion if necessary) The objective of the perineal phase of an APR
for low rectal cancer is to excise the anal canal
with a wide margin. The initial elliptical incision
Perineal Phase Technique is deepened past the ischiorectal fat circumferen-
tially until the levator muscles are encountered.
A 2018 meta-analysis of 1663 patients found that The optimal location for entry into the abdominal
the prone approach for APR is associated with cavity is through the anococcygeal ligament pos-
decreased blood loss and operative time, with no teriorly (Fig. 9). The coccyx can be excised to
differences in the incidence of postoperative facilitate entry or a margin-negative resection [4].
wound infection or intraoperative rectal perforation The St. Marks perineal retractor or the Lone Star
(IOP). Positioning also did not affect circumferen- retractor may also be used during the perineal
tial resection margin (CRM) positivity or local phase of surgery.
Fig. 9 Traction on the anus with the arrow showing the Fig. 10 Traction on the mobilized anus and exterioriza-
position of the coccyx tion of the proximal end of the specimen
In a conventional APR (CAPR), the lateral

attachments of the levators to the distal rectum/
upper anal sphincter are divided close to the
bowel. This type of dissection frequently pro-
duces a “waisted” specimen where the abdominal
and perineal dissections meet. This was reported
to increase the rate of IOP, CRM positivity, and
local recurrence. The extralevator abdominoperi-
neal excision (ELAPE) approach, described by
Holm et al. in 2007 [29], produces a more “cylin- Fig. 11 APR specimen
drical” specimen by avoidance of dissection of
the mesorectum off the levators during the suture a gauze to the staple line during the
abdominal phase and complete (wide) excision abdominal phase; the gauze is then inserted into
of the levators during a prone perineal phase. A the presacral space and can be easily identified
recent meta-analysis shows that ELAPE reduces upon entry into the abdominal cavity during the
IOP and local recurrence rates, without increas- perineal phase. With the proximal and distal
ing perineal wound complication rates, when ends of the bowel already mobilized, the speci-
compared with CAPR [30]. The RELAPe ran- men can be dissected off the prostate or vagina
domized trial also showed no difference in com- anteriorly. The ideal APR specimen should have
plications with ELAPE, and in addition found a an intact mesorectum without “waisting”
statistically significant reduction in CRM positiv- (Fig. 11). The wound is cleansed thoroughly
ity rates, compared to non-ELAPE [31]. We rec- before the transabdominal drain is located and
ommend the extralevator approach for locally appropriately positioned within the pelvis prior
advanced tumors involving the levators or exter- to closure (Fig. 12).
nal sphincters and tumors with a threatened CRM The perineal wound can be closed primarily or
following NACRT. using a mesh or flap. If a mesh is used, the edges
Following division of the posterior and lat- are sutured to the insertions of the excised levator
eral attachments, the proximal end of the speci- muscles to close the tissue defect at the level of
men can be exteriorized (Fig. 10). A method to the pelvic floor, providing support and theoreti-
facilitate the proximal exteriorization is to cally reducing the risk of perineal herniation.
Fig. 13 Closure of the perineal wound using interrupted

Fig. 12 The perineal wound is closed over the drain in
mattress suture and a subcutaneous drain
the pelvis
or ELAPE is performed (moderate quality

Biologic mesh is preferred over synthetic due to evidence)
reduced adhesions with small bowel, as well as • There is insufficient evidence to recommend
the better infection risk profile in a contaminated one particular method of perineal closure over
field. another following neoadjuvant radiotherapy
The 2017 Association of Coloproctology of • There is insufficient evidence to support a par-
Great Britain and Ireland (ACPGBI) Position ticular method of perineal wound closure fol-
Statement on the closure of the perineal defect lowing laparoscopic approach to APR
after APR for rectal cancer makes the following
relevant recommendations/findings [32]: In a CAPR, the remnant levator muscles
should be used to reconstruct the perineal defect.
• Primary closure of the perineum can be used The subcutaneous tissue is then approximated in
following CAPR (strong recommendation) multiple layers. A subcutaneous drain may reduce
• Mesh closure has rarely been used for perineal the risk of infection (Fig. 13).
wound closure following CAPR (moderate
quality evidence)
• When concerns regarding perineal wound Complications and Management
healing exists, myocutaneous flap closure may
be considered as an alternative method (weak During deep pelvic surgery, injury to the ureters,
recommendation) prostate, seminal vesicles, vagina, autonomic
• Primary perineal wound closure following nerves, sacral venous plexus, and internal iliac
ELAPE has been reported and appears to be vessels can occur. Membranous urethral injury is
feasible (weak evidence) a risk during the anterior portion of the perineal
• Biologic mesh has been used to reconstruct dissection; this risk can be possibly reduced with
the perineal defect after ELAPE (moderate prone positioning and exteriorization of the prox-
quality evidence) imal end of the specimen after distal, posterior,
• Perineal wound complications are signifi- and lateral mobilization as previously described.
cantly increased when neoadjuvant radiother- While current evidence is inconclusive, ELAPE
apy is delivered, regardless of whether CAPR surgery is theoretically at higher risk for perineal
wound complications due to the larger perineal necessary to facilitate healing but the patient is
defect and lack of muscle closure. A 2014 meta- advised to avoid squatting for 3 weeks as this
analysis of 32 studies reported that the pooled position may increase tension on the perineal
percentage of perineal wound complications in wound closure. The perineal wound must be
patients who did not undergo neoadjuvant radio- examined for possible complications prior to
therapy was 15.3% after CAPR versus 14.8% discharge.
after ELAPE. After neoadjuvant radiotherapy,
perineal wound problems occurred in 30.2% of
CAPR versus 37.6% following ELAPE [33]. References
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predicts survival outcomes: MERCURY experience. PJ. Perineal wound healing after abdomino-
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22. Bujko K, Rutkowski A, Chang GJ, Michalski W, review and meta-analysis. Dis Colon Rectum.
Chmielik E, Kusnierz J. Is the 1-cm rule of distal 2014;57(9):1129–39.
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ical evidence? a systematic review. Ann Surg Oncol. C. LOREC group the LOREC APE registry: operative
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23. Park JS, Park SY, Kim HJ, Cho SH, Kwak SG, Choi healing after abdominoperineal excision. Color Dis.
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advanced low rectal cancer. Dis Colon Rectum. inoperineal excision (eLAPE): a systematic review.
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Laparoscopic Total Colectomy
Mina Ming Yin Shen and William Tzu-Liang Chen
Introduction tissue which is usually encountered in severe,

complicated Crohn’s disease or in diverticulitis
Total colectomy (TC) with ileorectal (IRA) is fre- may not also be resectable via laparoscopy due to
quently performed for colorectal cancer, familial the tissue friability, bleeding, and distorted anat-
adenomatous polyposis, unidentified bleeding omy that necessitates open exposure. There are
from the lower GI tract, inflammatory bowel dis- no common criteria to apply laparoscopic tech-
ease, and sometimes for extended diverticulosis nique for combined resection for T4 colon can-
or colonic inertia. Minimally invasive approaches cer. Tumor invasion into other organs is not an
to total colectomy have significantly lower mor- absolute contraindication if en bloc resection
bidity compared to open approach, with signifi- could be achieved. However, laparotomic conver-
cantly shorter hospitalization length [1]. sion is necessary if oncologically curative resec-
tion is not achieved laparoscopically. Significant
intraoperative hemorrhage, in the presence of
Contraindications visceral lesion, incorrect dissection, all condi-
tions that may affect the outcome, are contraindi-
The most common relative contraindications to cations of laparoscopy and the conversion is
laparoscopic procedures are preoperative abdo- necessary.
mens caused by adhesion formation, coagulopa-
thy, cirrhosis, aberrant anatomy, small bowel
obstruction, disseminated abdominal cancer, pul- Preoperative Assessment
monary compliance and cardiovascular issues,
and intracranial disease. Certainly, hemodynami- All patients undergoing colonic surgery should
cal instability or cardiopulmonary disease that is have the same preoperative workup including
severe enough to make peritoneal insufflation anesthetic workup regardless of the surgical
and Trendelenburg positioning dangerous repre- approaches. All patients should have a complete
sent a physiologic derangement that precludes history and physical examination. Adjunct testing
the safe application of laparoscopy. Phlegmonous such as blood test, additional imaging (CT scan,
MRI), or cardiopulmonary testing is performed
when indicated. The only special consideration
M. M. Y. Shen · W. T.-L. Chen (*)
for laparoscopic surgery is ensuring that the sur-
Surgery, China Medical University Hsinchu Hospital, geon can identify the site of pathology at the time
Zhubei City, Hsinchu County, Taiwan of operative intervention. The loss of tactile sen-
e-mail: wtchen@mail.cmuh.org.tw sation in laparoscopic surgery stresses the impor-
https://doi.org/10.1007/978-981-19-3755-2_73
538 M. M. Y. Shen and W. T.-L. Chen
tance of localizing techniques, especially for OT Setup (Fig. 1a–c)

small lesions. These can be evaluated preopera-
tively by colonoscopy and tattooing of the lesion Authors routinely placed patients in lithotomy
can be performed during the colonoscopy position with both arms tucked and the thighs
1–2 days prior to the surgery especially for early positioned using stirrups at no more than a 10°
colonic cancer which ensures the oncological safe angle to the torso. Lithotomy allows simultane-
margins. It is helpful to have flexible colonoscopy ous access to abdomen and perineum for ileo-
in the operating room as it may be needed intraop- rectal anastomosis when using the circular
eratively to identify lesions if the location of the stapler, as well as for an intraoperative colonos-
lesion remains doubtful. All elective colonic copy. It also provides additional space for a sec-
resections should follow ERAS preoperative pro- ond assistant and an additional position for the
tocol. The protocols include perioperative opioid- operating surgeon when performing D3 dissec-
sparing analgesia, avoidance of nasogastric tubes tion at the superior mesenteric artery (SMA)
and peritoneal drains, aggressive management of and superior mesenteric vein (SMV) root. The
postoperative nausea and vomiting, and early oral patient should be fixed securely on the table
feedings and ambulation. Mechanical oral bowel because the patient’s position could be changed
preparation is not needed for elective laparoscopic during the operation. A beanbag is used to
TC. A urinary catheter is placed at the beginning secure the patient to the table, along with rein-
of the procedure and is removed on the first morn- forcement by adhesive tapes wrapping the
ing after the operation. Prophylaxis antibiotic and patient’s chest to the table. The patient’s posi-
deep vein thrombosis (DVT) prophylaxis should tion can be adjusted intraoperatively at the stage
be included. of splenic flexure, hepatic flexure, or rectal
Fig. 1 (a) Patient positioning in Trendelenberg position (b) Surgeon and assistants standing position during approach
of left side colon (c) Surgeon and assistants standing position during approach of right side colon
Laparoscopic Total Colectomy 539
b c
Camera man
Assistant
1st Camera man

Surgeon Nurse
Nurse assistant
Surgeon
Fig. 1 (continued)
mobilization. The procedure is usually per-

formed with one or two assistants. During the
procedure of central vascular ligation (CVL)
from SMA and SMV, the surgeon may stand in
between the patient’s legs. When mobilizing
from splenic flexure to rectum, the surgeon will
stand on the patient’s right while the camera
assistant on the surgeon’s right. The monopolar
device with hook, spatula, or scissor or energy-
based devices are adapted for the plane dissec-
tion, depending on the surgeon’s preference.
The adaptation of energy-based devices in lapa-
roscopic colon cancer surgery could reduce
chyle leakage, minimize bleeding on dissection
planes, and facilitate complete plane dissection.
Surgical Techniques
Fig. 2 Port placement for TC
Port Placements (Fig. 2)
Five trocars are placed. By open technique, Operatives Details

Camera port is inserted infra or supra umbilically
using balloon trocar. Pneumoperitoneum Approach of Right Side Colon
12–15 mmHg is created and abdomen is inspected
for findings. Two 12 mm ports are placed in the Colon Mobilization (Fig. 3a–d)
right lower quadrant and 2 cm superior to the Once the patient is positioned in a Trendelenburg
pubic symphysis at the midline. A 5 mm port is position with the left side down, the omentum,
placed in the right hypochondrium and a second small bowel, and transverse colon are swept in a
5 mm port is placed over left-sided abdomen. cephalad direction. The terminal ileum is lifted
a b
c d
Fig. 3 (a) Tenting the terminal ileum mesentery and num and pancreatic head are exposed (c) Ileocolic artery
mobilization of the retroperitoneum using monopolar cau- and vein (arrowed) take-off from SM pedicle (d) Middle
tery (b) At the medical extent of mobilization, the duode- colic artery (arrowed) branching off from SMA
anteriorly toward the abdominal wall (refer to placed at the dissected area to demarcate the
Fig. 3a), exposing the cleavage plane between dissected plane.
ileal mesentery and retroperitoneum. Peritoneum
overlying this plane is scored with either mono- CVL
polar diathermy or an advanced energy device. Prior to commencing the CVL, the mesentery of
As dissection proceeds along Toldt’s fascia, the the ascending and transverse colon is spread out to
ileal mesentery and posterior aspect of the right visualize the location of the ileocolic (IC), middle
colon are mobilized off the retroperitoneum. The colic (MC), and superior mesenteric (SM) pedicles.
authors routinely leave the lateral attachments of The peritoneum overlying the pedicles is scored.
the colon untouched, as this helps to provide Next, the terminal ileum is located and the proxi-
additional counter traction. mal transection point is decided. Using an energy
During dissection in the superior direction, device, a mesenteric window is created adjacent to
it is important to look out for the duodenum the proximal transection point. A laparoscopic sta-
and subsequently dissect anterior to it. In the pler is introduced through this window to transect
author’s practice, the medial extent of dissec- the ileum. The ileal mesentery is divided using an
tion is reached when the duodenum and pan- energy device in the direction of the SMA pedicle.
creatic head are exposed (refer to Fig. 3b). At the junction of the IC and SM pedicles, fine
Further mobilization is performed in toward dissection is performed to skeletonize the vessels
the direction of Morrisons’ pouch until the dis- and demonstrate the take-off of the IC from the SM
section plane is separated from Morrisons’ vessels (refer to Fig. 3c, d). Failure to demonstrate
pouch by a layer of peritoneum. A gauze is this could lead to inadvertent ligation of the SM ves-
sels, resulting in excessive small bowel ischemia. In transverse colonic mesentery. The main MC ves-
the event that initial vessel identification is in ques- sels are dissected free and ligated. The gastro-
tion, it is advised that dissection continues along the colic trunk is usually identified and preserved.
SM pedicle in the cephalad direction; dissected ves-
sels subsequently arising from the SM pedicle will Approach of Left Side Colon
provide more information on vascular anatomy.
After ligation of the IC pedicle, the next vessel Vascular Pedicle Isolation and Ligation
to be ligated is the right colic artery should it be (Fig. 4a–e)
present. Approximate location of the middle colic Patient is tilted head down 15° (Trendelenberg)
(MC) pedicle can be located via inspection of the and right side down for gravitational drag of
a b
c d
Fig. 4 (a) Incision of transverse mesocolon at the level inferior border of the pancreas (d) D3 lymph node dissec-
below lt-MCA to enter the lesser sac (b) The Treitz ligation at the IMA root (e) IMA is divided near the origin
ment is dissected with maximum care not to damage the from abdominal aorta
jejunum (c) The IMV is divided at the level close to the
small bowel to the right and omentum and trans- instrument can be inserted into the plane between
verse colon slightly to cephalad. Omentum is the mesentery and the retroperitoneum, lifting the
swept cephalad direction and transverse mesoco- mesentery toward the anterior abdominal wall
lon is lifted up to expose the cleavage plane of the without grasping and tearing tissue. Dissection
pancreas. Incision of transverse mesocolon at the carried on cephalad till the root of IMA with
level below lt-MCA either by monopolar dia- careful identification and preservation of hypo-
thermy or energy device to enter the lesser sac gastric nerves, which control urinary and sexual
(Fig. 4a). The Treitz ligament is dissected with function. With D3 lymph node dissection at the
maximum care not to damage the jejunum IMA root (Fig. 4d), the IMA is divided near the
(Fig. 4b). The peritoneal layer medial to the infe- origin from abdominal aorta (Fig. 4e).
rior Mesenteric Vein (IMV) is incised paralleled
to the vessel. The IMV is easily visualized, or in Splenic Flexure Mobilization (Fig. 5a, b)
case of more obese patients, search for, right The splenic flexure of colon is mobilized using
below the inferior of the margin of the pancreas. medial-to-lateral approach. After the procedures
The IMV is dissected free and then divided at the of central vascular ligation, the lessor sac has
level close to the inferior border of the pancreas been entered through the TM window and the
(Fig. 4c). mesentery root of left colon is incised. By inser-
The medial-to-lateral (MTL) approach to the tion of retracting instrument and tenting of mes-
left mesocolon easily brings the inferior mesen- entery of both transverse and descending colon,
teric artery (IMA) into view. The root of sigmoid the pancreatico-colonic ligament is divided using
mesentery is retracted up to create tension on the either monopolar diathermy or advanced energy
peritoneum which is then incised using monopo- devices (Fig. 5a). Lifting the IMV arch allows
lar diathermy from caudal to cephalad position furthering MTL dissection by opening a window
starting from the sacral promontory. Pneumo- between the Toldt fascia anteriorly and the
dissection might help to open up further the Gerotal fascia posteriorly (Fig. 5b). The border
embryological plane. The mesentery of the sig- between the two fascias, which indicates the
moid can be retracted away from the retroperito- embryonic plane of coalescence of posterior
neum by performing a blunt and bloodless mesocolon and retroperitoneum is whitish, a
dissection using a monopolar or advanced energy clear sign of correct dissection plane (Fig. 5b). A
device. Proper Medial-To-Lateral (MTL) dissec- tough elevation of mesocolon anteriorly toward
tion will not expose the left ureter, left gonadal the abdominal wall facilitates the dissection as
vessel, and psoas muscle, which are left far as the pericolic gutter, and downward to the
undisturbed retroperitoneally. The retracting
level of the sacral promontory.
a b
Fig. 5 (a) The pancreatico-colonic ligament is divided (b) Dissection between the Toldt fascia anteriorly and the
Gerotal fascia posteriorly
a b
Fig. 6 (a) Gently retract the descending colon medially, the Toldt’s fascia is divided (b) Division of the spleno-colic
ligament (c) Division of the gastrocolic ligament
Mobilization of Colon (Fig. 6a–c) identified, the rectal wall is dissected circumfer-
If the medial approach was done adequately, entially. Transanal distal rectal washout is intro-
colon (descending and sigmoid) can be easily duced, and then the section of the distal margin is
mobilized from the Toldt’s fascia. Gently retract performed with laparoscopic linear staplers. A
the descending colon medially, this thin Toldt’s suprapubic Pfannenstiel mini-laparotomy with-
fascia is scored and divided using monopolar dia- out muscles division is carried out and, after plac-
thermy and advanced energy devices (Fig. 6a). ing a wound protector, the specimen is retrieved.
The splenic flexure proper can then be dissected The terminal ileum is exteriorized and the staple
down by dividing the spleno-colic ligament line is resected. The anvil of a circular stapler is
(Fig. 6b). The greater omentum is separated from inserted through the end of the ileum, and perfo-
the gastric curvature. The gastrocolic ligament is rates the anti-mesenteric border, leaving 5 cm of
also divided (Fig. 6c). The sigmoid, descending the terminal ileum distal to the anastomosis. The
colon, and transverse colon are fully mobilized. rod of anvil is fixed to the ileum bowel wall by a
purse-string suture (Fig. 7a). The end of the ileum
Construction of Anastomosis is closed using a mechanical stapler or manual
and Specimen Extraction (Fig. 7a–c) suture. Then the bowel is placed back into the
Following this, the entire colon and the terminal abdomen and pneumoperitoneum is reestab-
ileum are mobilized and freed. The initial dissec- lished. The correct position of the ileum is
tion plane at the level of the upper rectum is iden- checked to eliminate any eventual twisting of the
tified, at the level of the promontory where the mesentery (Fig. 7b). The circular stapler is intro-
posterior mesorectal plane is identified and the duced through the anus and assembled with its
initial “holy plane” is dissected using monopolar head to perform side-to-end ileorectal anastomo-
scissors. Once the distal extent of resection is sis at the level of the promontory under laparo-
a b
Fig. 7 (a) The rod of anvil is fixed to the ileum bowel wall by a purse-string suture (b) Check the correct position of
the ileum (c) Side-to-end ileorectal anastomosis
scopic control (Fig. 7c). The donuts must be

evaluated to ensure that they are complete. Reference
Intraoperative colonoscopy is performed to check
1. Moghadamyeghaneh Z, Hanna MH, Carmichael JC,
the completeness of the anastomosis or anasto- Pigazzi A, Stamos MJ, Mills S. Comparison of open,
mosis site bleeding. In some cases, a drain is laparoscopic, and robotic approaches for total abdomi-
placed for postoperative surveillance. nal colectomy. Surg Endosc. 2016;30(7):2792–8.
Laparoscopic Ventral Mesh
Rectopexy
Isaac Seow-En, EmileTan Kwong-Wei,

and WilliamTzu-Liang Chen
Introduction graded using validated questionnaires for consti-

pation or fecal incontinence. Up to a third of
Rectal prolapse (RP) is a disabling condition and patients with RP have concomitant symptoms of
can range from internal rectal prolapse (IRP) or anterior compartment prolapse, including urinary
rectal intussusception to full-thickness external incontinence and vaginal vault prolapse.
rectal prolapse (ERP). RP occurs in 0.5% of the Decreased anal sphincter tone is often present,
general population, with a higher incidence in and proctoscopy may show an anterior solitary
females and the elderly [1].Intellectual disability rectal ulcer in 10–15% of cases. Straining in the
and psychiatric conditions are a risk factor for squatting position may be required to induce
RP in younger patients. Patients with an IRP ERP.
usually experience functional symptoms of If the diagnosis of IRP is uncertain, fluoro-
obstructed defecation (OD) or fecal incontinence scopic or MRI defecography should be per-
(FI), while patients with ERP suffer from pain, formed. A transit marker study can be considered
rectal bleeding, and FI [2].Two recent guidelines to assess symptoms of slow transit constipation,
have been published on the management of rec- which is a relative contraindication to surgery.
tal prolapse, the 2017 American guidelines [1] Anorectal function tests including manometry
and the 2017 Dutch guidelines [2].The recom- and anorectal physiology studies may be useful if
mendations in this chapter are summarized from IRP is suspected based on bowel symptoms, and
these sets of guidelines as well as additional up- results may alter management. In patients with
to-date evidence. OD, pelvic floor muscle dyssynergia is a contra-
The evaluation of a patient with suspected RP indication to rectopexy. ERP is an absolute indi-
should include a thorough history and physical cation for surgery; therefore, imaging and
examination. Bowel symptom severity should be anorectal function tests generally do not add any
further value to management. Patients with vari-
I. Seow-En ous functional symptoms arising from multicom-
Department of Colorectal Surgery, Singapore General partment prolapse should be discussed in a
Hospital, Singapore, Singapore multidisciplinary setting to achieve optimal
Division of Colorectal Surgery, China Medical decision-making. For selected patients, psychiat-
University Hospital, Taichung, Taiwan ric evaluation may be necessary to exclude a psy-
E. Kwong-Wei · W.-L. Chen (*) chosomatic origin of symptoms. Endoscopic
Division of Colorectal Surgery, Department of colonic evaluation should be performed to rule
Surgery, China Medical University Hsinchu Hospital,
Zhubei City, Hsinchu County, Taiwan out malignancy. Patients with functional symp-
e-mail: wtchen@mail.cmuh.org.tw toms from IRP must be considered for
https://doi.org/10.1007/978-981-19-3755-2_74
c onservative therapy, including lifestyle modifi- autonomic nerve-sparing, addressed the anterior
cation, pharmacological treatment, pelvic floor lead point of an IRP, and corrected a concomitant
physiotherapy, and retrograde colonic irrigation, rectocele, resulting in significant improvement in
if available. postoperative constipation and no incidence of de
novo constipation.
A recent 2018 meta-analysis [4] of 17 studies
Choice of Surgery (13 retrospective studies, three randomized trials,
and one prospective cohort study) with 1242
Although associated symptoms can be alleviated patients undergoing LVMR for ERP showed a
with conservative management, RP cannot be mean complication rate of 12.4%, with a mean
corrected without surgery. Surgical intervention ERP recurrence rate of 2.8% over a median fol-
should be tailored to the patient’s overall health low-up duration of 23 months, and mean rates of
status, concomitant pelvic organ prolapse, and improvement in fecal incontinence and constipa-
history of previous procedures. A host of differ- tion of 79.3% and 71%, respectively. Median
ent techniques have been described in the litera- operating time was about 120 min and conversion
ture, with two main approaches, perineal versus to open surgery was necessary in 1.8% of patients.
transabdominal. The choice between the two is Acceptable long-term outcomes have also been
usually determined by the surgeon’s preference published; the 10 year recurrence rate following
and experience as well as the patient’s comor- LVMR was 8.2% with a 4.6% mesh-related com-
bidities and bowel function. The most performed plication rate (1.3% vaginal mesh erosion) in 919
perineal methods are the perineal rectosigmoid- patients [6]. 76% of patients reported subjective
ectomy (Altemeier procedure) and perineal functional symptom relief at a median follow-up
mucosal sleeve resection with muscular plication time of 44 months from surgery [7].
(Delorme procedure). The most common trans- In view of these findings, the LVMR has
abdominal techniques are the anterior rectopexy become the most popular laparoscopic technique
with or without sigmoid resection, and the ven- for RP, particularly in Europe. The 2017 Dutch
tral mesh rectopexy. guidelines recommend the LVMR as the first-
Previous evidence reported that transabdomi- choice procedure for ERP as well as IRP with an
nal approaches resulted in lower recurrence rates indication for surgery [2]. Although resection rec-
and better functional outcomes compared to a topexy is thought by some to improve symptoms
perineal approach [1]. However, a 2015 Cochrane of constipation in patients with a redundant sig-
review of 15 randomized trials involving 1007 moid colon, there is no evidence favoring it over
patients was unable to demonstrate a significant LVMR and the risk of an anastomotic leak must
difference in the recurrence rate between an be considered. The robotic-assisted LVMR is sim-
abdominal or perineal technique [3]. A 2015 ran- ilar to LVMR in terms of functional outcome,
domized trial comparing laparoscopic ventral complication, and recurrence rates, although it
mesh rectopexy versus the Delorme procedure requires a longer operative time and increased
similarly did not show a statistically significant costs [8, 9]. Further evidence is required to deter-
difference in the incidence of recurrence or com- mine if the potential technical benefits of robotic
plication rates [4]. surgery translate to better clinical outcomes.
Open rectopexy is associated with higher
postoperative morbidity compared to laparo-
scopic or perineal surgery. The well-documented OT Setup
advantages of minimally invasive surgery in the
early postoperative period also make laparoscopy Bowel preparation using 2 L polyethylene glycol
preferred over open rectopexy. Laparoscopic is used. Below-knee compression stockings are
ventral mesh rectopexy (LVMR) was described applied and a urinary catheter is inserted. The
by D’Hoore et al. in 2004; [5] this technique was patient is placed in the modified Lloyd-Davis
Laparoscopic Ventral Mesh Rectopexy 547
Camera man
12 mm Assistant
Surgeon
5 mm 5 mm
12 mm
Nurse
Fig. 1 OT setup and port placement
position with the lower limbs in foot stirrups. steep Trendelenburg position, the uterus is tem-
Both arms are tucked in to facilitate positioning porarily hitched to the anterior abdominal wall
of the surgeon, camera operator, and assistant. A using a Prolene 2–0 straight needle passed
small sandbag (or folded drapes) is placed below through the uterus fundus or broad ligaments
the sacrum to elevate the pelvis approximately (Fig. 2). With the surgical assistant providing
4–5 cm anteriorly to enable better visualization traction on the sigmoid out of the pelvis and to
of the deep pelvic structures during surgery. A the left, the peritoneum is incised from the sacral
single dose of prophylactic intravenous antibiot- promontory to the pouch of Douglas (Fig. 3). The
ics is given at anesthetic induction. A schematic rectum is not mobilized laterally or posteriorly,
of the operating setup and port positioning is and the right hypogastric nerve is preserved,
shown in Fig. 1. A 12 mm camera trocar is placed decreasing injury to the parasympathetic and
at the umbilicus. A 12 mm trocar is placed at the sympathetic rectal innervation. The rectovaginal
right iliac fossa and two 5 mm trocars are placed septum is carefully opened down to the pelvic
at the right and left flanks. floor, avoiding injury to the rectum (Fig. 4).
Choice of mesh is an important consideration.
In D’Hoore’s original description, a 3 × 17 cm
Surgical Technique polypropylene mesh was used [10]. A 2017 sys-
tematic review of eight studies from 2004 to 2015
Essential steps and technique compared 3517 patients using synthetic mesh
1. Dissection and 439 patients using biological mesh for
2. Mesh fixation LVMR, with the rates of mesh-related erosion at
3. Vaginal fornix fixation 1.9% and 0.2%, respectively [11]. The largest
4. Neo-Douglas formation series of biological mesh used with the longest
follow-up was published in 2017 [12]. Of 224
We use the technique as described by D’Hoore patients who underwent LVMR using Permacol™
for LVMR in 2006 [10]. With the patient in a biological mesh, mesh-related morbidity was
Fig. 2 (Above) A straight needle is passed from the skin

through the fundus of the uterus. (Below) The uterus is Fig. 3 (Above) Blue line shows the extent of peritoneal
hitched to the anterior abdominal wall to provide better incision from the sacral promontory to the pouch of
access to the deep pelvis Douglas. Black line shows the position of right hypogas-
tric nerve. (Below) The incision is carried to the left-most
edge of the pouch of Douglas
0.5%, with a 11.4% recurrence rate. There was

significantly improved constipation, fecal incon-
tinence, quality of life outcomes, and associated
improvement in urogynecological symptoms.
We use a 10 × 10 cm, 1 mm thick Permacol
mesh, cut and stitched together using Prolene 2–0
sutures to fashion a [3, 13] × (15–20) cm strip of
mesh. The mesh must be long enough to allow
the distal end to reach the anterior rectal pelvic
floor and the proximal end to be secured to the
sacral promontory. If available, the 4 × 18 cm
1 mm thick Permacol mesh will be better suited
for this purpose. The mesh is sutured to the distal
Fig. 4 The rectovaginal septum is opened down to the rectum using Prolene 2–0, with four sutures on
pelvic floor
Fig. 6 The mesh is secured to the sacral promontory

Fig. 5 Interrupted Prolene 2–0 sutures are placed on
using laparoscopic tacks
either ventrolateral edge of the distal rectum. The row of
sutures can be seen where the square mesh was divided
and fashioned into a single strip
each ventrolateral edge of the rectum (Fig. 5).

The sutures are applied with the aid of a knot-
pusher from distal to proximal at approximately
1 cm intervals, beginning at the level of the pelvic
floor. Although the RP should be reduced at the
time of mesh fixation, no traction should be
exerted on the rectum, which remains along the
curve of the sacrococcygeal hollow [10]. The
mesh is fixed onto the sacral promontory using a
laparoscopic tacker (Fig. 6). Next, the posterior
vaginal fornix is sutured onto the distal aspect of
the mesh. This closes the rectovaginal septum
and corrects a rectocele (Fig. 7). Excess proximal
Fig. 7 The rectovaginal septum is recreated by suturing
mesh is trimmed following fixation (Fig. 8). the vaginal fornix to the ventral aspect of the mesh
Fig. 9 The peritoneum is closed from the left lateral

Fig. 8 The mesh is trimmed after fixation incised edge to the sacral promontory, completely cover-
ing the mesh
The peritoneum is closed over the mesh using
a continuous PDS 2–0 suture, commencing
from the left lateral edge of the peritoneal inci- Complications and Management
sion to the sacral promontory (Fig. 9). The
pouch of Douglas is recreated by approximating A 2015 study looked at data from 2203 patients
the peritoneum to the rectal serosa above the from five centers undergoing LVMR from 1999
rectovaginal colpopexy. In this manner, the to 2013 [14]. Synthetic mesh was used in 80% of
entire mesh is covered, preventing future adhe- patients versus biological mesh in 20%. Non-mesh
sion to the small bowel (Fig. 9). The uterine morbidity occurred in 11% (including pain, port site
hitch is removed. No abdominal drain is placed. complications, urinary retention, or infection). The
Finally, the abdominal wounds are closed, con- overall rate of mesh erosion was 2.0% (2.4% syn-
cluding the surgery. thetic mesh and 0.7% biologic mesh), including 20
vaginal, 17 rectal, 7 rectovaginal fistula, and 1 peri- 6. Consten EC, van Iersel JJ, Verheijen PM, Broeders
neal, at a median time to erosion of 23 months. Of IA, Wolthuis AM, D’Hoore A. Long-term outcome
after laparoscopic ventral mesh Rectopexy: an obser-
patients who suffered mesh erosion, 50% required vational study of 919 consecutive patients. Ann Surg.
treatment for minor erosion morbidity includ- 2015;262(5):742–7; discussion 747-8
ing local excision of stitch or exposed mesh. 40% 7. Mäkelä-Kaikkonen J, Rautio T, Kairaluoma M,
underwent intervention for major erosion morbidity Carpelan-Holmström M, Kössi J, Rautio A, Ohtonen
P, Mäkelä J. Does ventral Rectopexy improve pelvic
including operative mesh removal, colostomy cre- floor function in the long term? Dis Colon Rectum.
ation, and anterior resection of rectum. 2018;61(2):230–8.
8. Ramage L, Georgiou P, Tekkis P, Tan E. Is robotic
ventral mesh rectopexy better than laparoscopy
Postoperative Care in the treatment of rectal prolapse and obstructed
defecation? A meta-analysis. Tech Coloproctol.
2015;19(7):381–9.
No further antibiotics are given beyond the induc- 9. Albayati S, Chen P, Morgan MJ, Toh JWT. Robotic
tion dose. The urinary catheter can be removed vs. laparoscopic ventral mesh rectopexy for external
on postoperative day 1 or 2, and the patient is dis- rectal prolapse and rectal intussusception: a system-
atic review. Tech Coloproctol. 2019;23(6):529–35.
charged following bowel motion. The patient is
10. D'Hoore A, Penninckx F. Laparoscopic ventral
advised to avoid excessive straining, and a course recto(colpo)pexy for rectal prolapse: surgical tech-
of stool bulking agents may be required. nique and outcome for 109 patients. Surg Endosc.
2006;20(12):1919–23.
11. Balla A, Quaresima S, Smolarek S, Shalaby M,
References Missori G, Sileri P. Synthetic versus biological
mesh-related erosion after laparoscopic ventral mesh
Rectopexy: a systematic review. Ann Coloproctol.
1. Bordeianou L, Paquette I, Johnson E, Holubar SD,
2017;33(2):46–51.
Gaertner W, Feingold DL, Steele SR. Clinical prac-
12. McLean R, Kipling M, Musgrave E, Mercer-Jones
tice guidelines for the treatment of rectal prolapse. Dis
M. Short- and long-term clinical and patient-reported
Colon Rectum. 2017;60(11):1121.
outcomes following laparoscopic ventral mesh rec-
2. van der Schans EM, Paulides TJC, Wijffels NA,
topexy using biological mesh for pelvic organ pro-
Consten ECJ. Management of patients with rectal pro-
lapse: a prospective cohort study of 224 consecutive
lapse: the 2017 Dutch guidelines. Tech Coloproctol.
patients. Color Dis. 2018;20(5):424–36.
2018;22(8):589–96.
13. Emile SH, Elbanna H, Youssef M, Thabet W,
3. Tou S, Brown SR, Nelson RL. Surgery for complete
Omar W, Elshobaky A, Abd El-Hamed TM, Farid
(full-thickness) rectal prolapse in adults. Cochrane
M. Laparoscopic ventral mesh rectopexy vs Delorme's
Database Syst Rev. 2015;2015(11):CD001758.
operation in management of complete rectal pro-
4. Emile SH, Elfeki H, Shalaby M, Sakr A, Sileri P,
lapse: a prospective randomized study. Color Dis.
Wexner SD. Outcome of laparoscopic ventral mesh
2017;19(1):50–7.
rectopexy for full-thickness external rectal prolapse: a
14. Evans C, Stevenson AR, Sileri P, Mercer-Jones MA,
systematic review, meta-analysis, and meta-regression
Dixon AR, Cunningham C, Jones OM, Lindsey I. A
analysis of the predictors for recurrence. Surg Endosc.
multicenter collaboration to assess the safety of
2019;33(8):2444–55.
laparoscopic ventral Rectopexy. Dis Colon Rectum.
5. D'Hoore A, Cadoni R, Penninckx F. Long-term out-
2015;58(8):799–807.
come of laparoscopic ventral rectopexy for total rectal
prolapse. Br J Surg. 2004;91(11):1500–5.
Part XXI
Robotic Surgery
Robotic Surgery: Operating Room
Setup and Docking
Sajid Malik
Introduction Practical Applications
Robotic surgery (RS) continues to impart its role Robotic surgery has successfully made it possi-
in minimally invasive surgery (MIS) since its first ble to complete complex and advanced surgical
emergence. It has rapidly been adopted by differ- procedures with precision while staying with
ent specialties including general surgery, urol- the promises of minimally invasive techniques
ogy, gynecology, and orthopedic surgery, and [5]. Many surgeons around the globe have
now is becoming a mainstay of MIS technique already been practicing RS in all specialties and
around the globe [1–3]. During the last 30 years, disciplines like urology, general surgery, pediat-
many different robotic systems came into surgi- ric surgery, neurosurgery, gynecology, cardiac,
cal practice but the da Vinci® is currently the and orthopedic surgery. It has been further
most commonly utilized and is available in four applied to subspecialties of general surgery like
different models (standard, streamlined, stream- colorectal, hepatobiliary, bariatric and anti-
lined High definition, S-integrated). Despite its reflux surgery, gastric oncology, endocrine, her-
enhanced view of 3D system and angulations of nia, and complex abdominal wall reconstruction
instruments, its practical application for training [1, 5, 6].
surgical residents is less emphasized and In contrast to 2D view of laparoscopic sur-
addressed [4, 5]. This chapter will guide in the gery, operating surgeon is sitting comfortably on
basic principles of setting operating room and consol with physical ease, enjoying 3D view with
equipments for da Vinici®. It is further empha- depth perception. Robotic arm manipulation and
sized that hands-on training on simulators and in 360 articulation is the beauty of RS which allows
operating rooms under a trained mentor is highly the surgeon to perform a more complex proce-
suggestive of learning robotic skills. dure without much strain [5–7].
Limitations
RS has few limitations despite rapidly develop-

S. Malik (*) ing technique. Cost and safety always remained
Department of Surgery, National University Hospital, questionable in this technique [8, 9]. Human
Singapore, Singapore error along with mechanical failures of RS com-
Department of Surgery, Allama Iqbal Medical ponent like robotic arm, lens, camera, and instru-
College, Jinnah Hospital, Lahore, Pakistan ments can completely halt the procedure. Extreme
https://doi.org/10.1007/978-981-19-3755-2_75
556 S. Malik
body positions can cause nerve palsies in inexpe- irrigation, retraction, changing instruments, and
rienced hand [1, 8, 9]. must have basic laparoscopic skills [12].
Bulkiness of RS set may be overcome in large
institute with dedicated RS operation suite but
lack of tactile sensations and force feedback are asic Requirements for Robotic
B
still a major drawback of this technique [9–11]. Surgery
The basic system for robotic surgery consists of

Surgical Team three components: Vision Cart, Patient Cart, and
Surgeon’s Cart (Console) (Fig. 1). Other require-
Minimum surgical team required to run RS setup ments are according to the type of surgery. This
is surgeon, surgical assistant, circulating nurse, chapter will try to include the basic minimum
and surgical technician. All surgical staff should requirements for any robot-assisted surgical
be trained in robotic surgery and must have basic procedure.
knowledge of it which must be gained by proper
training. This team should be persistent and dedi-
cated for RS cases to achieve a good learning Minimum Personnel Required
curve. Surgeon and assistant must not only have
mastering skills in operating Da Vinci but also • Trained robotic surgeon
have basic knowledge of RS system and also be • Anesthesia Team trained to conduct robotic
aware of troubleshooting the system. Surgical surgery
assistant play a vital role and should be efficient • Trained surgical assistant(s)
enough in trocar placement, draping, docking, • One/two trainees or residents
VISION CART PATIENT-SIDE CART SURGEON-SIDE CART
Fig. 1 Vision cart, Patient-side cart, and Surgeon-side cart

Robotic Surgery: Operating Room Setup and Docking 557
• Circulating nurse
• OR technicians
Laparoscopic Instruments
Assistant
• Veress needle (optional) Nurse

• 12 mm × 1 Optiview Visiport for camera port
• 12 mm Xcel port × 2
• 6 mm port × 2
• Metzenbaum scissors
Surgeon at
• Hook cautery, Maryland dissector, Needle console
driver
• 5 mm × 1 Hem o lok clips and its applicator
• 10 mm × 1 Hem o lok clips and its applicator
• 0 and 30° scopes
• Suction irrigation setup
Fig. 2 Operating room setup
Robotic Instruments
booms can harbor insufflators, electrosurgical
• da Vinci robotic system (Intuitive surgical, units, camera, and light source equipment.
CA, US) Operating room should be arranged in a fashion
• 8 mm robotic trocar × 2 that surgeon has a clear view of the patient from
• 5 mm robotic trocars × 3 console with a clear pathway for OR staff to
• Camera adapter move around (Fig. 2).
• Sterile camera trocar mount and drapes
• Sterile drapes for camera and instrument arms
• Sterile camera mount and instrument adapter Patient Position and Preparation
• Endowrist instruments
In contrast to conventional laparoscopic surgery,
extreme positioning is required in order to
Operating Room Configuration achieve optimized exposure for robotic surgery
procedures and often requires a strong teamwork
Operating Room Setup to ensure patient safety [13]. Patient safety con-
cerns during RS are to maintain circulation, nerve
Conventional operating room (OR) can be used protections, and pressure injuries to bony promi-
to set up RS system but, due to its size and extra nences. Every effort should bring in consider-
component, it is advised to have a dedicated RS ation to provide proper exposure of surgical site,
room to accommodate not only the system and adequate room for anesthetists to proceed.
also to allow free movement of OR personnel. It Another main concern regarding positioning is
will further allow docking of the robot from dif- the safe docking of robot and safe access for bed-
ferent angles depending on the type of surgery. side surgeon to the surgical ports [14].
Availability of space could be a major issue for For ventral hernia, patients are directly
already established OR setups but this problem moved onto OR table in supine position with
can be overcome by restructuring operating room both arms tucked in by the side of body. Arms
according to the need. Some of the components can be placed in a sling or arm boards to opti-
may be placed on vision cart. Ceiling-mounted mize the access of da Vinci arms. All the bony
558 S. Malik
prominences and pressure areas should be cov- ommended to refer to manual for color coding
ered with a gel pad. Patient cart approach side and numbering of arms for standard or S model.
should be lifted up. The patient is then exposed (Fig. 3).
in a way that he could be prepped from xiphoid An extra and very useful feature of Touch
to perineum and can be approached from any screen monitor is to use it to draw real-time
side if needed [15]. images on monitor. This feature is very useful
for teaching and training surgical residents and
should be emphasized to use it during surgery to
Patient Cart Position let them know about surgical steps and
techniques.
Patient cart should be sterilized and draped before
bringing into surgical field. Once the patient
positioning is set and cart itself is draped, it Vision Cart Position
should be moved in by using motor drive. Patient
cart brakes are designed by default to stop if it is The vision cart should be next to patient cart in
not in use, but it is advised to refer to the manual order to visualize the component display and also
setting for safety concerns [14, 15]. to prevent uninterrupted and free movement of
Patient cart for standard systems has camera camera cable during surgery. It contains many
and instrument arms. Each arm has several joints storage areas to harbor different equipment. It
and clutches for gross movements and also to typically contains light source, video processor,
insert and withdraw instruments. These arms and camera control. It can further house insuffla-
have two clutch buttons. One dedicated to free tors, DVD recorders, and electrosurgical units.
gross movement and the other to adjust final tra- Light source is connected with endoscope by a
jectory of arm for final docking. The author single cable and the endoscope comes in 0°and
advises to refer to the system manual for clutch 30° lense and further has a right and left optical
settings as wrong movements can lead to a major channel to record images. While the standard or S
disruption. Third arm is in alignment with cam- type higher robotic systems endoscopes are con-
era arm therefore care must be taken into account nected with higher magnification of 15× with 45°
to avoid sword fighting of arms. It is further rec- view or wider view of 60° with 10× magnifica-
a b
Fig. 3 Position of patient cart on patient for docking (a, b)

tion. Resolution and aspect ratio of images can be created using either open or closed technique, the
set from manual and new systems are designed author was working with MIS team and recom-
with higher resolutions and AR. mends to proceed with open technique to better
avoid injury. Once peritoneum is accessed,
12 mm visiport for da Vinci endoscope must be
Steps of Docking introduced and secured in place.
Positions of various ports could vary from
bdominal Access and Port
A patient to patient according to the procedures and
Placement is also depended upon the surgeon’s preference
(Fig. 4). In order to have optimum working con-
Abdominal access and port placement are very ditions, the following principles should be kept in
crucial to start RS. Pneumoperitoneum can be mind.
a b
Assistant
Port
Working Working
Port1 Port2
Camera
Port
Fig. 4 Port placement (a), Position (b), and Docking with an extra assistant port (c)
560 S. Malik
• Camera port should be in the same line as sur- • Camera arm and other instruments should be
gical target area positioned in ways that smooth functioning
• Target area should not be more than 20 cm and movements can be observed during
from camera port procedure.
• Working ports should be at least 8 cm form • After initiating homing sequence, camera,
camera port on each side endoscope, instruments, and touch screen are
• Assistant port, if needed, should be atleast draped and locked.
4 cm from camera port • Similar to laparoscopic setting, proceed with
white balance.
Ports placement in robotic complex ventral • Align camera port towards targeted anatomi-
or lateral hernia is a critical step and patient fac- cal area and surgical cart center column.
tors and anticipated docking should be kept in • Lock the wheels once cart is in position.
mind before this step. Patient BMI, body habi- • “Sweet spot” (arrow is pointing towards thick
tus, previous surgery, defect orientation, and its blue line) of camera arm should be set by
size may affect port positioning and minor bringing the trocar mount in alignment with
amendments can be done accordingly. Port the center of the patient cart column and also
should be placed as much laterally as possible by simultaneous extension of camera arm.
and after insufflations up to 15 mmHg. Assess • Check the set up joint angles to minimize the
defect orientation and mark the site. Consider potential collision. The angle at the second
additional 3–5 cm for mesh placement around joint should be 90°.
the defect. Mark the anticipated mesh perimeter • System is ready to use and is docked (Fig. 5).
at which fixation will be considered latterly.
Draw a semicircular line around the mesh
perimeter marking, 10–12 cm away from mesh Console Function and Terminology
perimeter. Camera port should be placed on this
line exactly opposite to anticipated patient cart. Surgeon should be aware of the console’s differ-
Two working arms ports should be placed on ent part and terminology being used. Basic termi-
each side of camera port almost 8 cm away and nology according to the site is mentioned in the
on semicircular line. It is better to place assis- picture (Fig. 6).
tant port at this stage if needed. Later, once
docking is done, we cannot move the patient or • Clutch plate
patient cart afterward. Assistant port is placed • Camera peddle
almost 4 cm from camera port and at least 6 cm • Focus bar
away from the semicircular line. These port • Cautery peddle
placements are critical for surgery because this
will ultimately bring optimal triangulation [15].
Preparing da Vinci
Operating room preparation should be started

well before patient’s arrival in preoperative area.
Surgical team can follow steps that should be
considered while setting up system for surgery.
• Before turning on the system, it is advised to

connect all cables necessary to run it and do
not manipulate system until it is on and self-
testing is done. Fig. 5 Docked system
Stereoviewer
Stereoviewer
Master
Control Master Control
&
Touch
Pad
User Interface
User Control (Left)
Interface
Control
Footswitch Panel
Foot
Switch
Panel
Fig. 6 Surgeon’s Cart/Console and its various parts
Left Side Inserting/Changing Instruments

Left side of console bears the following buttons
and controls Always start by straightening the instrument tip
and slide it to port to bring under vision. Push the
• Stop angle button instrument into surgical area by pressing the arm
• Console height adjustment button clutch button. If any resistance is felt during this
• Fault reset button manure, stop and check to identify the problem
and address it accordingly. Surgeon should only
Right Side proceed to drive once the LED light indicator is
• On/Off button “ON” (Fig. 7).
• Ready button
• Emergency stop button
562 S. Malik
robots. Robotic surgery procedure has dramati-

cally increased during the last decade. Complete
understanding of instrumentation, knowledge
of robotic system, and robotic program hinges
on a proper OR is a mainstay for successful out-
come. Well trained, enthusiastic, dynamic, and
knowledgeable surgical team is a key for OR
dynamics to provide excellent quality care to
patients.
Acknowledgments Professor Davide Lomanto.

Professor of Surgery, National University of Singapore.
Fig. 7 Control and Clutch with LED indicator ON to Senior Consultant & Director, Advance Surgical
proceed Training Centre.
National University Hospital, Singapore.
Instruments Removal
References
Instruments being removed should be straight-
ened and jaws should be visualized. Before pro- 1. Palep JH. Robotic assisted minimally invasive sur-
ceeding with instrument removal, make sure that gery. J Minim Access Surg. 2009;5(1):1–7.
2. Sudan R, Desai SS. Emergency and week-
no tissue is being held in the jaws of instruments. end robotic surgery are feasible. J Robot Surg.
Simply press the release lever on instrument 2011;6(3):263–6.
housing and take out the instruments. 3. Farivar BS, Flannagan M, Leitman IM. General
surgery residents’ perception of robot-assisted
procedures during surgical training. J Surg Educ.
2015;72(2) article no. 990:235–42.
System Shutdown 4. Ghezzi TL, Corleta OC. 30 years of robotic surgery.
World J Surg. 2016;40(10):2550–7.
Once the surgery is completed, all the instruments 5. Moorthy K, Munz Y, Dosis A, et al. Dexterity
enhancement with robotic surgery. Surg Endosc.
are removed first same as laparoscopic surgery, 2004;18:790–5.
followed by endoscope removal. Arms are discon- 6. Marescaux J, Rubino F. The ZEUS robotic system:
nected from the trocars and patient cart is experimental and clinical applications. Surg Clin
undocked from the patient. New system does not North Am. 2003;83:1305–15.
7. Tholey G, Desai JP, Castellanos AE. Force feedback
allow undocking by no activation of motor drive plays a significant role in minimally invasive surgery:
system until the instruments and camera are results and analysis. Ann Surg. 2005;241:102–9.
removed and undocked. 12 mm trocar incision or 8. Townsend CM Jr, Beauchamp RD, Evers BM, Mattox
any other incision more than 12 mm should be KL. Sabiston textbook of surgery E-book. Elsevier
Health Sciences; 2016.
considered for fascial closure. 8 mm or 5 mm tro- 9. Morgan JA, Thornton BA, Peacock JC, et al. Does
car incision is not required to be closed. All steril- robotic technology make minimally invasive cardiac
ized drapes or clothes used should be removed surgery too expensive? A hospital cost analysis of
and system can be switched off. If there is any robotic and conventional techniques. J Card Surg.
2005;20:246–51.
subsequent case, it is better to keep the system on. 10. Camarillo DB, Krummel TM, Salisbury JK. Jr robotic
technology in surgery: past, present, and future. Am J
Surg. 2004;188:2S–15S.
Conclusion 11. Hubens G, Ruppert M, Balliu L, Vaneerdeweg
W. What have we learnt after two years working with
the da Vinci robot system in digestive surgery? Acta
Limitations of conventional laparoscopy like Chir Belg. 2004;104:609–14.
3D visualization and good ergonomics have 12. Gettman MT, et al. Current status of robotics in uro-
been overcome by the use of technology of logic laparoscopy. Eur Urol. 2003;43(2):106–12.
13. Guideline for positioning the patient. In: Guidelines 15. Lomanto D, Malik S. Robotic repair of ventral her-
for perioperative practice. Denver, CO: AORN, Inc; nias. Ann Laparsc Endosc Surg. 2019;4:61. https://
2014. p. 563–81. doi.org/10.21037/ales.2019.05.13.
14. Molloy BL. Implications for postoperative visual loss:
steep Trendelenburg position and effects on intraocu-
lar pressure. AANA J. 2011;79:115–21.
Part XXII
Other Laparoscopic Procedures
Laparoscopic Varicocelectomy
Rakesh Kumar Gupta
Introduction a relatively high incidence of postoperative dis-

comfort [8] and for this reason the modified
Varicocele is defined as dilated and tortuous Palomo procedure was often preferred [9].
veins of the pampiniform plexus of scrotal Ivanissevich described a procedure where the
veins. Varicocele occurs in approximately 15% testicular vein is tied at the inguinal ring and the
of the male population [1] and 21–39% of infer- testicular artery is spared [8]. In 1991 Aaberge et al.
tile men [2]. introduced laparoscopic varicocelectomy as the
Clinically, there are three grades for varico- new and less invasive treatment for varicocele [10].
cele [3]. In recent years laparoscopic varicocele ligation
(LV) had been popularized and had gained growing
• Grade I. The patient is standing and varicocele acceptance. The built-in magnification of the lapa-
appears while the scrotum is palpated and roscope facilitates identification of the spermatic
Valsalva maneuver is done. veins and artery, potentially reducing the risk of
• Grade II. Varicocele appears while the scro- recurrence of the varicocele and of ischemic dam-
tum is palpated without Valsalva maneuver. age to the testis. Magnification also allows the sur-
• Grade III. Varicocele appears as a “bag of geon to preserve lymphatics and the genital
worms” while the patient stands, without branches of the genitofemoral nerve that runs along
Valsalva and palpation. the spermatic vessels, which may reduce lympho-
cele formation and postoperative pain [11].
Despite extensive information being available Laparoscopic management of varicoceles in
on varicoceles and many studies on different sur- adults may reflect the excellent visibility of the
gical solutions, the ideal method of varicocele posterior abdominal wall achieved using the lap-
ligation is still a matter of controversy. The ideal aroscope, which allows a thorough search of sites
technique would have low recurrence and com- known to be responsible for recurrent varico-
plication rates [4]. celes, viz., renal, vas associated, pelvic, and ret-
Different approaches have been applied for ropubic cross-over veins [11].
the treatment of varicocele, including open sur- The conventional technique of laparoscopic
gery, sclerotherapy, and, recently, laparoscopy varix ligation is to ligate the vessels with clips
[5–7]. The Palomo technique was associated with and then transect them in between the clips [12–
14]. Sasagawa reported that they successfully
R. K. Gupta (*)
transected the internal spermatic vessels purely
GS & MIS Unit, Department of Surgery, B.P. Koirala using a harmonic scalpel, which comes only in
Institute of Health Sciences, Dharan, Nepal diameters of 5 and 10 mm [15].
https://doi.org/10.1007/978-981-19-3755-2_76
568 R. K. Gupta
Indications Preoperative semen analysis should be car-

ried out in all patients aged 18 years and above.
American Urological Society recommends that Pre-anesthetic checkup was done. After the
varicocele treatment should be offered to the patients were considered fit for surgery, they
male partner of a couple attempting to conceive were informed in their native language about
when all of the following are present. the nature of the disease process, the proce-
dure, the possible complications of the proce-
1. A varicocele is palpable. dure, the possibility of conversion of
2. The couple has documented infertility. laparoscopic surgery to open in cases of diffi-
3. The female has normal fertility or potentially culty and about the hematoma, wound infec-
correctable infertility. tions, pneumoscrotum, hydrocele, prolonged
4. The male partner has one or more abnormal pain, and recurrence.
semen parameters or sperm function test
results.
Surgical Technique
The indications in adolescents—presence of
significant testicular asymmetry (⧼ > 20%) dem- Operation theater setup is done as shown in
onstrated on serial examinations, testicular pain, Fig. 1. The procedure is performed under general
and abnormal semen analysis results. Very large anesthesia. A prophylactic intravenous antibiotic
varicoceles may also be repaired; however, in the (third generation cephalosporins IV) is given at
absence of atrophy, this indication is relative and induction prior to the incision. The patient is
controversial. placed in a supine position.
Once painting and draping are done pneumo-
peritoneum is created either by open or closed
Preoperative Assessment technique, depending upon the surgeon’s prefer-
ence. In Open technique, 10 mm transverse infra-
A proper history regarding the onset of symp- umbilical port is made and pneumoperitoneum is
toms to its presentation is important. General created with CO2 at 2–3 liters/minute and an
physical examination followed by a proper clini- intra-abdominal pressure of 10–12 mmHg is
cal examination of external genitalia, groin, and
the testis.
Once the clinical diagnosis of varicocele is
made, routine preoperative investigations were
done, for fitness of general anesthesia.
Ultrasonographic examination can be done for
the evaluation of:
(a) Enlarged veins along the spermatic cord and

epididymis.
(b) Diameter of the largest vein while the patient
performed a Valsalva maneuver in a standing
position.
(c) Reflux in the veins during the Valsalva
maneuver.
(d) Grade of the varicoceles.
(e) Detect other pathologies in the right or left
retroperitoneum that might have caused a
varicocele. Fig. 1 Operative Setup
Laparoscopic Varicocelectomy 569
Fig. 3 Laparoscopic view of right spermatic vessels
Fig. 2 Landmarks with trocar sites
obtained. A 30° laparoscope is then inserted and

the abdominal cavity was evaluated. Two 5 mm
trocars were inserted as in Fig. 2.
Landmarks: pubic symphysis, anterior supe-
rior iliac spines. Surgical preparation field: well
above umbilicus, lateral to iliac spines, penis and
scrotum. Fig. 4 Dissection of parietal peritoneum exposing right
spermatic vessels
Trocar placement left side

• • 5 mm supra-umbilical trocar for camera and
insufflation
• 5 mm trocar halfway to two-thirds between
the umbilicus and pubic symphysis in the mid-
line (for unilateral case)
• 5 mm trocar on ipsilateral side of the varico-
cele, lateral to the epigastric vessels around
the line of the umbilicus (for bilateral cases
two 5 mm trocars on each side).
Patient is then placed in a slight reverse

Trendelenburg position and tilted to the opposite
side of the operative field (10–15°). Abdominal Fig. 5 Dissection and identification of gonadal vessels
and vas
organs are assessed. Internal spermatic vessels
are identified (Fig. 3).
Peritoneum overlying the left or right internal The testicular veins are sealed with suture/clips/
spermatic veins are opened (Fig. 4). harmonic scalpel (depends upon the surgeon’s
Veins are dissected, testicular artery, artery o preference). Hemostasis is secured and con-
vas deference must be identified and preserved. firmed (Figs. 5, 6).
570 R. K. Gupta
–– Hydrocele (5%)
–– Epididymo-orchitis
–– Prolonged pain (5–6%)
–– Recurrence (5–20%)
Laparoscopic ligation is an effective and safe

approach to achieve pain relief in varicocele
patients [16].
Postoperative Care
After the surgery, they are shifted to the wards for

Fig. 6 Ligation and division of right spermatic vessels postoperative care.
• A standard analgesic regimen was adminis-

Skin is closed with skin staplers and a sterile tered (intramuscular Diclofenac 75 mg 8
dressing is applied. hourly and on demand).
• Pain measurement was done using Visual
Troubleshooting in identifying testicular Analog Scale (VAS score).
artery: • Antibiotics were not used beyond the intraop-
1. For identification of the internal spermatic erative period.
artery, use of a laparoscopic Doppler is help- • Feeding was resumed as soon as there was a
ful, especially as often the artery will stop pul- full regain of consciousness.
sating after manipulation.
2. Papaverin injection can also be used to differ- Patients were discharged on the following day
entiate artery and veins. The Doppler probe after assessment with proper medical advice
used to identify pulsation also helps with including the date of suture removal and they
dissection. received similar instructions to return to normal
activity.

References
• Intraoperative complications
–– Damage to the vessels in the area (inferior 1. Hopps C, Lemer M, Schlegel P, Goldstein
M. Intraoperative varicocele anatomy: a microscopic
epigastric artery, inferior mesenteric vein, study of the inguinal versus subinguinal approach. J
spermatic vessels). Urol. 2003;170(6):2366–70.
–– Injury to the vas. 2. Greenberg SH, Wallach E. Varicocele and male fertil-
–– Transection of the genitofemoral nerve. ity. Fertil Steril. 1977;28(7):699–706.
3. Itoh K, Suzuki Y, Yazawa H, Ichiyangi O, Miura
• Immediate complications M, Sasagawa I. Results and complications of lapa-
–– Port site Hematoma roscopic Palomovaricocelectomy. Arch Androl.
–– Wound complications (2%) 2003;49(2):107–10.
–– Subcutaneous emphysema (20%) 4. Hassan J, Adams M, Pope J, Demarco R, Brock
J. Hydrocele formation following laparoscopic
–– Pneumo-scrotum (15%) Varicocelectomy. J Urol. 2006;175(3):1076–9.
–– Postoperative pain 5. Kocvara R, Dvoracek J, Sedlacek J, Dite Z, Novak
• Long-term complications K. Lymphatic sparing laparoscopic varicocelectomy:
–– Testicular atrophy (3%) a microsurgical repair. J Urol. 2005;173(5):1751–4.
6. Misseri R, Gershbein A, Horowitz M, Glassberg
–– Genitofemoral nerve injury K. The adolescent varicocele. II: the incidence of
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hydrocele and delayed recurrent varicocele after cence after laparoscopic Varicocelectomy. J Urol.
varicocelectomy in a long-term follow-up. BJU Int. 1995;153(4):1175–7.
2001;87(6):494–8. 13. Pianalto B, Bonanni G, Martella S, Renier M, Ancona
7. Palomo A. Radical cure of varicocele by a new tech- E. Results of laparoscopic bilateral varicocelectomy.
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8. Ivanissevich O. Left varicocele due to reflux; experi- 14. Huscher C, Lirici M, Di Paola M, Crafa F, Corradi
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10. Donovan J, Winfield H. Laparoscopic Varix Ligation. lescents using an ultrasonically activated scalpel.
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Yoshida O. Smaller ports result in shorter convales-
572 R. K. Gupta
Laparoscopic Pediatric Inguinal
Hernia Repair
Hrishikesh Salgaonkar and Rasik Shah
Inguinal hernia repair is one of the commonest the deep or internal inguinal ring after reduction
elective surgical procedure performed in the of contents. In girls, the hernial sac is transfixed
pediatric age group. The incidence of inguinal and divided at the level of the internal ring along
hernia in children varies between 1 and 5% and is with the round ligament [1, 2]. With the advent of
more commonly seen in premature infants. minimally invasive surgery, many pediatric sur-
Similarly, it is more common in boys as com- geons repair the inguinal hernia laparoscopically
pared to girls. Almost always clinically diag- to achieve the same results. The main advantages
nosed by a palpable reducible lump in the are visualization of the opposite internal ring,
inguinal region, the mere presence of an inguinal decrease in the incidence of injury to vas and ves-
hernia in children is an indication of surgical sels, and esthetic small scars.
repair. Traditionally, pediatric inguinal hernias
are repaired by an open technique which involves
high ligation of the hernial sac at the level of the Anesthesia, Preoperative
internal ring. Laparoscopy is a safe, easy, and Evaluation, and Counseling
reproducible technique in the hand of an experi-
enced surgeon with similar results. In this chap- While open repair of inguinal hernia can be per-
ter, author discusses the details of the technique formed under caudal block or laryngeal mask
of laparoscopic inguinal hernia repair. anesthesia, laparoscopic repair is performed
under controlled general anesthesia with endotra-
cheal intubation. Also, during the learning curve,
Introduction laparoscopic repair takes more time compared to
open repair. Always counsel the parents and get
Pediatric inguinal hernia repair is a commonly consent for possible bilateral repairs, which is not
performed procedure by pediatric surgeons. It is uncommon to encounter.
due to the persistent processus vaginalis. Standard
open repair involves ligation of the hernial sac at
Theater Setup and Patient Position
H. Salgaonkar (*)
Department of Bariatric and Upper GI Surgery, The patient is placed in a supine position and
University Hospitals North Midlands,
properly secured to the operating table. The mon-
Stoke-on-Trent, UK
itor is placed at the foot end of the operating
R. Shah
table. The first port is inserted by an open tech-
SRCC Children’s Hospital, Narayana Health,
Mumbai, India nique while the surgeon is standing on the left
https://doi.org/10.1007/978-981-19-3755-2_77
574 H. Salgaonkar and R. Shah
side of the operating table and then the surgeon neum is incised at the level of the internal ring.
inserts the remaining ports and then he moves to The authors being right-handed surgeons, prefer
the head end of the operating table to carry out to start the incision from lateral to the medial
the surgery. direction for the right-side hernias and medial to
lateral for the left-side hernia.
Port Placement
Dissection of Hernial Sac
The first port (5 mm) is inserted at the superior
aspect of the umbilicus using an open technique Identify the cord structure (Vas and vessels in
and a 5 mm 300 telescope is inserted (alterna- the male) or round ligament (in females).
tively even 3 mm telescope gives good view Dissect carefully, with minimal handling of
while using HD camera). Pneumoperitoneum of cord structures to reduce damage due to tissue
8 mm of water is achieved by CO2 insufflation, handling. Continue dissection posterior to the
with a flow of 1–2 liters per minute. General deep ring to gradually isolate the hernial sac.
examination of the entire abdominal cavity is Continue dissection of the sac into the inguinal
performed and then the preliminary examination canal for only up to 2 cm to avoid unnecessary
of both internal inguinal rings is carried out to muscle damage (Fig. 1). The dissected sac is
check for their patency. Two additional (3 mm) excised using diathermy. In female children, if
working ports are inserted under laparoscopic meticulous care is taken, the sac can be safely
guidance on either side of the umbilicus in the dissected off the round ligament upto the level
midclavicular line in bilateral disease. This is to of the internal ring, avoiding the need for divid-
maintain at least 8–10 cm distance between the ing the round ligament.
entry site of the port and the internal ring. In case
of unilateral hernia, the 3 mm port on the oppo-
site side of the hernia can be placed a little lower Assessment of the Myo-Pectineal
and closer to the internal ring so as to achieve Orifice
better triangulation.
In newborns and infants, the ports can be At this point assess the approximation of the con-
inserted at a higher level to maintain adequate joint muscle with the inguinal ligament (inter-
working distance from the internal ring. Once the nally identified as the Ilio-pubic tract) at the
port placement is accomplished, the patient is internal ring. In case of poor approximation,
placed in a Trendelenburg position. Visual exam- suture the conjoint muscle with the ilio-pubic
ination of internal genitalia should be carried out tract lateral to the inferior epigastric vessels using
to rule out disorders of sexual differentiation 3–0 absorbable or nonabsorbable suture (better to
(DSD). use permanent suture like 3–0 polyester instead
of polyglycolic) on a round body needle [3]. Too
tight approximation is avoided and usually 1–2
Hernia Repair interrupted sutures are sufficient.
Peritoneal Incision
Closure of Peritoneal Defect
Author prefers to repair symptomatic side first in
case of a bilateral inguinal hernia. The peritoneal In children, it is easy to introduce the needle
lining at the internal ring is marked with dia- transabdominally as the abdominal wall is rela-
thermy on a hook or scissors. Then the perito- tively thin. The peritoneum in children at the
Laparoscopic Pediatric Inguinal Hernia Repair 575
a b
c d
Fig. 1 Steps of hernia repair (a) Identification of hernia (b) Marking of the peritoneal incision (c) peritoneal incision
(d) dissection of sac into the inguinal canal
internal ring is very thin and loose and it can be and 5 mm supra-umbilical incision is closed with
easily closed by a purse-string suture. As the 3–0 polyglycolic acid suture.
peritoneum is loose, it can be easily fed on the tip
of the needle instead of taking a bite with the
needle. This avoids any chance of injury to the Postoperative Care and Follow-Up
surrounding structures (Fig. 2). After closing the
peritoneal defect, the needle is removed along Feeding is resumed 3–4 h after the procedure and
with the port by holding the suture 1 cm away patients are discharged on the same day or the
from the swaged end of the needle. Even the her- next day morning. All patients are evaluated after
nial sac is then removed along with the trocar. 1 week, 1 month, 6 months, and then annually if
The 3 mm port sites are closed with steristrips, feasible.
Fig. 2 Excision of the hernial sac and purse-string closure of the internal ring
Other Techniques using an absorbable or nonabsorbable suture a

purse-string stitch is taken around the internal
The author prefers the abovementioned technique inguinal ring to approximate the crural arch and
of laparoscopic sac resection and peritoneal clo- conjoined tendon. In larger hernias, one or more
sure with an intracorporeal suture. There are mul- interrupted stitches are made.
tiple techniques of direct internal ring suture
closure without sac dissection and excision. This
may be achieved by intracorporeal or extracorpo- Laparoscopic Percutaneous
real suturing. Extracorporeal Closure
Under laparoscopic vision using a suture passer

aparoscopic Intracorporeal Purse
L device transabdominally, a suture is passed through
String a 2 mm stab incision and guided around the lateral
half of the circumference of the internal inguinal
In this technique, sac dissection is avoided. After ring. Through the same skin cut, pass the suture
incising the peritoneum around the internal ring, passer device around the medial half of the internal
Laparoscopic Pediatric Inguinal Hernia Repair 577
ring to withdraw the suture out creating a loop and sis, lesser pain, etc. By allowing us a visualiza-
tie the suture extracorporeally. Care is taken to tion of contralateral groin it offers us the
avoid damaging the vas deferens and testicular ves- advantage of simultaneous repair. Young sur-
sels. Based on surgeon preference different devices geons and trainees should not hesitate to call for
may be used to form a loop and close the internal help from seniors as the safety of patients is para-
inguinal ring with an extracorporeal knot under mount and should never be compromised.
laparoscopic vision, e.g., hollow bore nee-
dle—18 G, LPEC needle with a special wire loop
at the tip, Reverdin needle, herniotomy hook. Conclusion
Surgeons well versed in both open or laparo-

Complications scopic approaches can utilize the benefits of
either procedure. Laparoscopy offers more per-
Complications in pediatric inguinal hernia are operative information of both groins as compared
similar to standard laparoscopic inguinal hernia to open, and hence offers an advantage in case of
repair. Whether we perform an open or laparo- uncertain diagnosis, especially for infants or pre-
scopic hernia repair, every surgeon should follow maturely born neonates. It also seems better in
the basic principles of good surgical practice. It is those with recurrent hernias. In experienced
paramount to handle tissues carefully, perform a hands, laparoscopic inguinal hernia repair in chil-
meticulous dissection, have a good understand- dren is a safe and feasible procedure.
ing of the anatomy of the groin, safe use of energy
device, and secure hemostasis. If care is not taken
complications like bleeding, hematoma, wound References
infection, bowel/bladder injury, injury to vas or
gonadal vessels can occur. Injury to gonadal ves- 1. Glick PL, Boulanger SC. Inguinal hernias and
hydroceles. In: Grosfeld JL, O’Neill Jr JA, Coran
sels may lead to testicular atrophy. In girls dam- AG, Fonkalsrud E, editors. Pediatric surgery. 6th ed.
age to fallopian tubes is a possibility with future Philadelphia: Mosby; 2006. p. 1172–9.
implications of infertility, so care should be taken 2. Levitt MA, Ferraraccio D, Arbesman MC, Brisseau
to minimize handling. Post-op hydrocoele, scro- GF, Caty MG, Glick PL. Variability of ingui-
nal hernia surgical technique: a survey of north
tal edema/erythema, chronic pain, port site her- American pediatric surgeons. J Pediatr Surg.
nias are not unheard of. Excessive dissection of 2002;37(5):745–51.
the inguinal canal, tight sutures approximating 3. Shah R, Arlikar J, Dhende N. Incise, dissect, excise
conjoint muscle with ilio-pubic tract, inability to and suture technique of laparoscopic repair of pae-
diatric male inguinal hernia. J Minim Access Surg.
excise the hernia sac can all lead to recurrence. 2013;9:72–5.
Meta-analysis comparing laparoscopic vs open 4. Dreuning K, Maat S, Twisk J, van Heurn E, Derikx
pediatric inguinal hernia repair has not shown J. Laparoscopic versus open pediatric inguinal her-
any conclusive superiority of one over the other nia repair: state-of-the-art comparison and future
perspectives from a meta-analysis. Surg Endosc.
with similar operative times, perioperative 2019;33(10):3177–91.
results, and complication rates including recur- 5. Yang C, Zhang H, Pu J, Mei H, Zheng L, Tong
rence [4]. In fact, laparoscopy has been proven to Q. Laparoscopic vs open herniorrhaphy in the
be better for bilateral hernias and meta-chronic management of pediatric inguinal hernia: a sys-
temic review and meta-analysis. J Pediatr Surg.
contralateral hernias [5]. The recurrence rates for 2011;46(9):1824–34.
uncomplicated inguinal hernia repair in children 6. Ein SH, Njere I, Ein A. Six thousand three hundred
range between 1.2 and 2.8%, regardless of the sixty one pediatric inguinal hernias: a 35 year review.
child’s gender. This rate increases in premature J Pediatr Surg. 2006;41(5):980–6.
7. Zendejas B, Zarrouq AE, Erben YM, Holley CT,
infants and those with an incarcerated hernia [6, Farley DR. Impact of childhood inguinal hernia repair
7]. Laparoscopy offers us all the proven benefits in adulthood: 50 years of follow up. J Am Coll Surg.
of minimally invasive surgery, e.g., better cosme- 2010;211(6):762–8.

Mastering Endo-Laparoscopic and Thoracoscopic Surgery

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Mastering Endo-Laparoscopic and Thoracoscopic Surgery

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Mastering Endo-

Le Quan Anh Tuan

William Tzu-Liang Chen

MIS Education Asia

ISBN 978-981-19-3754-5 ISBN 978-981-19-3755-2 (eBook)

In almost a century of surgery, few advances can be compared to the changes

Singapore, Singapore Davide Lomanto

The historical development of laparoscopy can be traced back to early 1900s

Minimally invasive surgery, as it stands today, has been the result of

Part I Basic Principles

Part II Anesthesia in Laparoscopic Surgery

Part III Diagnostic Laparoscopy

Part IV Emergency Laparoscopy

Perforated Ulcer Treatment�������������������������������������������������������������������� 95

Part V Endocrine Surgery

Remote Access Endoscopic Thyroidectomy������������������������������������������ 139

Part VII Video Assisted Thoracic Surgery

Part VIII Upper Gastrointestinal Surgery: Esophageal Surgery

Part IX Upper Gastrointestinal Surgery: Gastric Surgery

Gastric Gastrointestinal Stromal Tumor ���������������������������������������������� 253

Part X Bariatric Procedures

Part XI Hepatobiliary Surgery: Gallbladder

Elective Cholecystectomy������������������������������������������������������������������������ 307

Part XII Hepatobiliary Surgery: Common Bile Duct Stones

Part XIII Hepatobiliary Surgery: Liver

Hepatic Cyst/Abscess ������������������������������������������������������������������������������ 321

Laparoscopic Splenectomy���������������������������������������������������������������������� 369

Part XVI Inguinal Hernia

Transabdominal Pre-peritoneal Approach (TAPP)������������������������������ 381

Laparoscopic Management of Recurrent and Re-recurrent

Part XVII Incisional/Ventral Hernia Repair

Laparoscopic Intraperitoneal Onlay Mesh (IPOM)

Part XVIII Diastasis Recti

Part XIX Other Hernias

Part XX Colorectal Surgery

Laparoscopic Right Hemicolectomy with Complete Mesocolic

Part XXI Robotic Surgery

Part XXII Other Laparoscopic Procedures

Laparoscopic Varicocelectomy���������������������������������������������������������������� 567

About the Editors

Davide Lomanto graduated with distinction (Magna cum Laude) in medi-

College of Surgeons of Edinburgh (FRCS). He is member of the International

Marilou B. Fuentes is a consultant and the training officer of the Department

William Tzu-Liang Chen is currently the superintendent of China Medical

Davide Lomanto, PhD, FAMS, FACS, FRCS Minimally Invasive Surgery

William Tzu-Liang Chen Division of Colorectal Surgery, Department of

Marilou B. Fuentes, FPCS, FPSGS, FPALES Department of Surgery, The

Narendra Agarwal, MBBS MS, FCPS Department of Thoracic Surgery,

Alembert Lee-Ong, FPCS, FPSGS, FPALES Department of Surgery,

Arnel Abatayo, MD, FPSGS, FPCS, FPALES Department of Surgery,

Alfred Allen Buenafe, FPCS, FPSGS, FPALES Department of Surgery,

Koji Kono, MD, PhD Department of Gastrointestinal Tract Surgery,

Vincent Matthew Roble II, MD, FPSGS, FPCS Advanced Minimally

Sujith Wijerathne, MBBS, MRCS, MMed, FRCS, FAMS Minimally

Eva Lourdes Sta Clara

E. L. Sta Clara (*)

toneal cavity. Avoid moving side to side the

ing movement. The transparent tip allows direct

creation of the pneumoperitoneum. One should sus-

Singapore, Singapore Davide Lomanto

Part I Basic Principles

Part II Anesthesia in Laparoscopic Surgery

Part III Diagnostic Laparoscopy

Part IV Emergency Laparoscopy

Perforated Ulcer Treatment�� 95

Part V Endocrine Surgery

Remote Access Endoscopic Thyroidectomy�� 139

Part VII Video Assisted Thoracic Surgery

Part VIII Upper Gastrointestinal Surgery: Esophageal Surgery

Part IX Upper Gastrointestinal Surgery: Gastric Surgery

Gastric Gastrointestinal Stromal Tumor �� 253

Part X Bariatric Procedures

Part XI Hepatobiliary Surgery: Gallbladder

Elective Cholecystectomy�� 307

Part XII Hepatobiliary Surgery: Common Bile Duct Stones

Part XIII Hepatobiliary Surgery: Liver

Hepatic Cyst/Abscess �� 321

Laparoscopic Splenectomy�� 369

Part XVI Inguinal Hernia

Transabdominal Pre-peritoneal Approach (TAPP)�� 381

Laparoscopic Management of Recurrent and Re-recurrent

Part XVII Incisional/Ventral Hernia Repair

Laparoscopic Intraperitoneal Onlay Mesh (IPOM)

Part XVIII Diastasis Recti

Part XIX Other Hernias

Part XX Colorectal Surgery

Laparoscopic Right Hemicolectomy with Complete Mesocolic

Part XXI Robotic Surgery

Part XXII Other Laparoscopic Procedures

Laparoscopic Varicocelectomy�� 567

Introduction Care and Handling of Telescopes

Ultrasonic Energy Devices

HARMONIC scalpel (Ethicon Endo-Surgery,

Introduction dures contribute to the adverse performance of

General Principles Different types of needles:

Introduction Human errors have been classified in the fol-

Surgeons’ Body Posture

Position of Visual Display (Monitor)

Port Placement and Instruments

Ambient Room Lighting torsion of the scrubbed nurse/assistant while

Introduction adjunct hemostasis (tissue adhesives and seal-

Choice of Topical Hemostatic Agents sible, insert a gauze through a 10 mm port

Introduction specialty widely performing laparoscopic proce-

ccess Devices: Role