UPDATED TOPICS IN MINIMALLY INVASIVE ABDOMINAL SURGERY

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94 Updated Topics in Minimally Invasive Abdominal Surgery The median duration in the literature is around 2-3 hours 58 . In the authors experience laparoscopic left lateral resection can be performed as quick laparoscopically as open once the learning curve has been overcome. Transection time can be less than 1 hour as reported in a recent meta-analysis 59. For major hepatectomy operative times are prolonged and the duration of anaesthesia can be in excess of 5 hours compared to 3 hours for open surgery 60 61. This can be reduced by performing a hybrid resection or, using a hand-port as it is generally the parenchymal transection and dealing with the right hepatic vein that causes the prolonged pneumoperitoneum. In the UK most centres use epidural anaesthesia for post-operative pain relief but for LLR the duration of anaesthesia can be significantly reduced as an epidural and central venous pressure line are no longer required. Few studies have reported the consequences of the prolonged peritoneum. There is no doubt that increased intra-abdominal pressure reduces liver, renal lower limb and mesenteric blood flow. It also increases cardiac output and arterial pressures . The presence of obesity exacerbates these problems further. Careful consideration therefore needs to be given to those patients with significant renal and cardiac disease. There is also experimental evidence that prolonged peritoneum can impair post-operative liver regeneration, oxidative stress and hepatocellular damage 62. Sometimes the pneumoperitoneum can have advantages in that during bleeding a careful increase in intra-abdominal pressure can reduce bleeding and allow parenchymal transection without portal clamping. However prolonged pneumoperitoneum with portal clamping can cause a significant reduction in hepatic oxygen tensions, tissue hypoxia, with higher transaminase and increased tissue necrosis 63. Gas embolism is also thought to be of concern in that it can cause haemodynamic disturbance in 50% of episodes but usually has no clinical consequences as the solubility of carbon dioxide is greater than nitrogen. It is important to avoid high intra-abdominal pressures when dissecting the major venous structures in an effort to avoid this problem 64. By controlling the differential pressures between the pneumoperitoneum and central venous pressure the risk of air embolism can be reduced significantly. 5. Techniques of laparoscopic liver resection Definitions of laparoscopic liver surgery have been standardised. There are 3 techniques, totally laparoscopic, hand assisted and hybrid 11. Hand assisted can be used either at the start of the operation or introduced at any time to aid dissection. This is most often performed during right hepatectomy or major resection and to control bleeding. Hybrid procedures comprise either totally laparoscopic converted to hand assisted and then the operation is completed through a small incision usually this is for parenchymal transection or to aid mobilisation of the right or left lobe after hilar dissection. 5.1 Patient positioning During resection of the left lateral segment, and tumours within the anterior segments e.g. IVb, V, VI the patient is positioned in the supine position with split legs with the surgeon standing in between them and the assistants on each side (Figure 4). For tumours placed in the posterior segments (VI and VII), patients are positioned in the left lateral decubitus position. For those patients positioned supine with split legs, five ports (ENDO PATH Xcel , Ethicon Endosurgery, LLC, USA) are positioned; three 12 mm ports: the first at the umbilicus (sometimes higher if distance between the xiphoid and umbilicus is greater than 15 cm), the second and third working ports in the right and left mid clavicular line; and two
Laparoscopic Liver Surgery 5 mm ports in the right and left anterior axilliary line (Figure 5). For tumours positioned in segments IVa and VIII, high up towards the dome of the right diaphragm a further 10mm port is placed at the xiphisternum to allow for CUSA parenchymal division (Integra, Saint Priest, France, USA) Fig. 4. The surgeons preferred position for lap resection Fig. 5. Port position for lap left lateral resection 95
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UPDATED TOPICS IN MINIMALLY INVASIV
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free online editions of InTech Book
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VI Contents Chapter 9 Appendicitis
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Part 1 Laparoscopic Biliary-Pancrea
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4 Updated Topics in Minimally Invas
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10 Updated Topics in Minimally Inva
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14 Fig. 3. Incision of 3,5 cm in le
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Page 123: Part 3 Laparoscopic Appendectomy
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1. Introduction 10 Laparoscopic Her
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Laparoscopic Hernia Repair Absorba
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Laparoscopic Hernia Repair passes t
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Laparoscopic Hernia Repair The cont
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Laparoscopic Hernia Repair 2.3.3 TA
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Laparoscopic Hernia Repair testicle
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Laparoscopic Hernia Repair semicirc
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Laparoscopic Hernia Repair fascial
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Laparoscopic Hernia Repair elastic
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Laparoscopic Hernia Repair Laparosc
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Laparoscopic Hernia Repair defect.
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Laparoscopic Hernia Repair LeBlanc,
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1. Introduction 11 Laparoscopic Inc
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Laparoscopic Incisional Hernia Repa
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Part 5 Laparoscopic Solid Organ Sur
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202 5. Discussion Updated Topics in
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204 7. References Updated Topics in
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214 8. Surgery Updated Topics in Mi
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14 Laparoscopic Approach to Abdomin
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Laparoscopic Approach to Abdominal
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1. Introduction 15 Role of Endoscop
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Role of Endoscopy in Laparoscopic P
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UPDATED TOPICS IN MINIMALLY INVASIVE ABDOMINAL SURGERY

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