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Laparoscopic Surgical Procedures

The evolution of laparoscopic surgical procedures has advanced very rapidly since 1990.

Originally, gynecologists—followed by general surgeons, urologists, and chest surgeons—began using laparoscopic procedures to enhance diagnostic skills and offer treatment requiring relatively insignificant abdominal or chest incisions. The concept of this kind of surgery has advanced because of the increased availability of visual techniques via video monitoring and the development of instruments that allowed it to become part of the surgical armamentarium.

Guidelines for various laparoscopic procedures have been put forth by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). SAGES is the leading international organization for laparoscopic procedures, and its guidelines can be used on all levels for post-residency surgical education and training. Its Web site at www.sages.org can be accessed by surgeons as well as the public.

The discipline of surgery is dynamic and continues to evolve. Modifications of standard surgical procedures are generally introduced into clinical practice gradually. Integrating techniques or procedures that are new to individual surgeons, that represent a substantial change in existing methods or practices, or that necessitate the mastery of new technology usually require special training and changing privileges.

It should be noted, too, that robotic surgery is being used in some centers. This is an evolving technique that requires special training and experience.

Safeguards for Laparoscopy

The safety measures for laparoscopic surgery are the same as for open surgery: Good surgical judgment, proper patient selection, and techniques that offer the maximum safe results for the patient are necessary. Safety requires the surgeon to have appropriate training and education, with hands-on experience of laparoscopic surgery. A one- or two-day didactic course will generally not suffice because safe patient selection for lap surgery must always include the possibility of open surgery.

Preventing Injuries

The rush to perform laparoscopic cholecystectomy that began, for practical purposes, in 1990, has provided a great deal of information concerning the changes in the types of complications that were infrequently seen prior to laparoscopic surgery; i.e., the increased incidence of bile duct injuries that occurred.

Trocar injuries are another source of problems. The Hasson technique clearly prevents trocar injuries to the major blood vessels, but it does not completely protect the intestines. In general, this technique is considered to be a safer way to enter the abdomen, except perhaps with grossly obese patients. The Verres needle technique and the blind trocar technique with proper abdominal insufflation, control of the lower abdominal wall, and proper direction of the needle and trocar (45 degrees toward the pelvis) provide the maximum safety. Both techniques are within the standard of care.

The introduction of trocars into previous abdominal incisions should be avoided because of the potential for intestinal adhesions under the scar. Alternate site entries into the abdomen are acceptable in patients who have had multiple abdominal surgeries and who are grossly obese.

Diagnosing Problems Quickly

Since laparoscopic surgery presents the opportunity for less pain, speedier recovery, and a decrease in the length of the patient’s hospital or outpatient department stay, the diagnosis of complications that occur may be delayed because the patient is not under the usual in-hospital observation. Pain is one of the most important signs of a major postoperative complication such as perforated intestine or bleeding. When pain is out of proportion to what would be expected with laparoscopic surgery, rapid action must be taken with imaging devices (such as CT) and blood work, etc.

Because laparoscopic surgery is minimally invasive, the surgeon may have a false sense of security about the procedure that he or she has performed. This can result in a delay in the diagnosis of postoperative complications, which then becomes an issue concerning standard of care. Although the liberal use of cholangiography has been suggested by the SAGES guidelines, the standard of care does not demand it. Early diagnosis of major intraoperative and postoperative problems usually yields the best results for the patient.

It is also important to develop and implement a thorough and comprehensive informed-consent process in order to document the patient’s level of understanding of the procedure. Using communication techniques, such as “repeat-back,” will aid the surgeon in assuring patient comprehension of the procedure, and its risks and benefits.

Training

Laparoscopic cholecystectomy (as well as other advanced procedures currently being performed) has a learning curve for the surgeon to develop the expertise necessary to provide maximum safety to the patient. The learning curve varies among surgeons. Each surgeon’s technical ability is different, and the surgeon’s exposure in hospitals with more experienced laparoscopic surgeons varies, along with the opportunity to perfect techniques at animal laboratories or in simulation centers.

It should be mentioned that although residencies give surgeons more exposure to laparoscopic surgery than they received before 1990, residency programs do not necessarily give carte blanche for all procedures to recently trained surgeons. Fellowships in laparoscopic surgery fall into a different category that usually involve an additional one or two years. It is suggested in community hospitals that new procedures be performed with careful proctoring and, if possible, with colleagues with similar training who have more experience.

Credentialing, granting privileges, and reappointment for procedures are generally left up to individual hospitals. These guidelines are readily available on the SAGES Web site.

Patient Safety Recommendations

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