Minimally invasive surgery has been
with us for the past century. The lasl thirty
years have seen an exponential growth
in the development of laparoscopic
techniques which allow major surgery to
be performed through smaller incisions
and less trauma leading to enhanced
recovery and earlier discharge from
hospitalpeer-reviewe

Abela, Jo Etienne

English

OAR@UM

Advances in general surgicallaparoscopy Jo Etienne Abela '-to FRCS FEBS MF'til Consultant General and l aparoscopic Surgeon Introduction Minimally invasive surgery has been with us for the past century. The lasl thirty years have seen an exponential growth in the development of laparoscopic techniques which allow major surgery to be performed through smaller incisions and less trauma leading to enhanced recovery and earlier discharge from hospital. Diagnostics Diagnostic laparoscopy may be performed through 3 sub-centimetre incisions, allowing an accurate exploration of the peritoneal cavity. It has changed the management of the acute abdomen and the staging of upper gastrointestinal cancer. In the former setting, laparoscopy may be employed to make a confident diagnosis of appendicitis, Meckel 's diverticultitis, terminal ileitis, tubal and ovarian pathology, bowel ischaemia and visceral perforation. These conditions may be dealt with primarily by laparoscopy. In the oncological setting , low volume liver and peritoneal disease which is not readily identifiable by CT and PET, may be encountered. In these scenarios tumour upstaging will avoid unnecessary major surgery. Biliary surgery Laparoscopic cholecystectomy has now been performed for a few decades and was largely the primer to the development of most other laparoscopic operations. Aside from being the standard of care for the cold calculous gall bladder, it is fast becoming the treatment of choice (during the index admission) for the patient with acute biliary colic, acute cholecystitis and mild biliary pancreatitis. Intra-operative cholangiography may be performed with relative ease obviating the need for MRCP and ERCP. If bile duct stones are confirmed , laparoscopic bile duct exploration and clearance may be offered to provide a single-stage laparoscopic management. Hernia surgery Laparoscopic surgery has been successfully employed in the reconstruction of all forms of herniae. The totally extra-peritoneal approach (TEP) may be used for inguinal, femoral, obturator and Spigelian defects. Recurrent and bilateral defects are particularly suited to this approach. Intra-peritoneal techniques lend themselves well for the repair of large umbilical and incisional herniae, avoiding the otherwise large incisions which are associated with protracted pain and a high incidence of infection. Laparoscopy has revolutionalised the management of hiatal hernial defects. The sliding hernia associated with GORD may be treated with a crural repair and fundoplication. Large rolling (para-oesophageal) herniae containing stomach (Figure 1), but on . ........ - --,"" , ~ . . . . :~- '- :.'- : "' 4_;' ' : - .~ -. SAINT JAMES H OS PITAL Bfcause our fomiiy caUI Saint James Hospital George Borg Olivier Street, Sliema Saint James Square, Zabbar Tel: 2329 1000 occasions bowel and spleen, may be reconstructed with or without recourse to prosthetic implants (Figure 2) . Heller's myotomy for achalasia (with or without an anti-reflux procedure) is now also routinely performed. Resectional surgery Virtually, every abdominal and pelvic organ may be excised by laparoscopy. Splenectomy (Figure 3 and 4) , adrenalectomy, nephrectomy and colectomy are now being performed on a routine basis. In tertiary level centres hepatic, pancreatic and oesophago-gastric resections are still the province of the enthusiast. Figure 1: CT images showing gastric vo lvulllS in a rol ling hiatal hernia (hS:herniated stomach. S:obstructed stomach, d:diaghragm). Figure 2: Completed crural repair tlSing PTFE pledgets, AF:anterk>r fundopHcation. Figure 3: CT images 01 splenomegaly dllll to marginal zone lymphoma. GC:greater CUNe of stomach. A:splenic artery. P:tail of pancreas, V:splenic vein, ip: inferior pole of spleen) Figure 4: Patient in RgUfe 3. The 25cms spleen was morcelated and delivered throllgh a 3 cm incision in the left loin, 

Advances in general surgical laparoscopy

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Advances in general surgical laparoscopy

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