Indications and contraindications of Laparoscopy1

Indications and Indications and contraindications of contraindications of

LaparoscopyLaparoscopy

Video laparoscopy is a new tool in the surgical Video laparoscopy is a new tool in the surgical armentarium. Accordingly, it offers no new armentarium. Accordingly, it offers no new indications for surgery in established diseases, indications for surgery in established diseases, i.e. strategy of treatment is the same: i.e. strategy of treatment is the same: laparoscopy represents a change of tactics laparoscopy represents a change of tactics aiming for the same goals of standard surgery aiming for the same goals of standard surgery viz:viz: Safe;Safe; Low morbidity;Low morbidity; Maximum chance of cure in case of malignant Maximum chance of cure in case of malignant

disease.disease.

Indications of surgical Indications of surgical intervention in generalintervention in general::

Failed medical treatment;Failed medical treatment; Occurrence of complications.Occurrence of complications.

N.B.:N.B.: you could not do an operation you could not do an operation laparoscopically which you could not laparoscopically which you could not do by the open technique.do by the open technique.

Contra-indications of Contra-indications of laparoscopylaparoscopy : :

These are medical contra-indications These are medical contra-indications of pneumoperitoneum (gasless of pneumoperitoneum (gasless technique may be still applicable)technique may be still applicable)

Relative contra-Relative contra-indications of indications of LaparoscopyLaparoscopy::

Pregnancy;Pregnancy; Extensive abdominal adhesions;Extensive abdominal adhesions; Experience of surgeon versus extent of Experience of surgeon versus extent of

pathology;pathology; Adequacy of available instruments for the task.Adequacy of available instruments for the task. Thus in absence of frank contra-indications, almost Thus in absence of frank contra-indications, almost

all types of surgery can be done laparoscopically. all types of surgery can be done laparoscopically. The question is why laparoscopy?The question is why laparoscopy?

Inherent advantages of Inherent advantages of laparoscopylaparoscopy::

Operative:Operative:o Better visualization in some areas;Better visualization in some areas;o More fine dissection;More fine dissection;o Less blood loss;Less blood loss;o With improvement of learning curve With improvement of learning curve

possibly less operative time.possibly less operative time.

Inherent advantages of Inherent advantages of laparoscopylaparoscopy::

Post-operative:Post-operative:o Less pain;Less pain;o Less immunosuppression;Less immunosuppression;o Rapid recovery;Rapid recovery;o Less hospital stay and consequently Less hospital stay and consequently

shorter sick leaves;shorter sick leaves;o Less post-operative adhesions.Less post-operative adhesions.

The driving forces for The driving forces for laparoscopic laparoscopic

implementationimplementation:: Patient acceptance;Patient acceptance; Industrial and technological drive:Industrial and technological drive:

o Money investment;Money investment;o Shorter sick leaves.Shorter sick leaves.

Doctor’s acceptance (reviving Doctor’s acceptance (reviving general surgery).general surgery).

Actual limitations in IraqActual limitations in Iraq::

Relative high cost:Relative high cost:o Hospitals;Hospitals;o Private patients;Private patients;o Third parties.Third parties.

Learning curves;Learning curves; Medical profession fears:Medical profession fears:

o Long term follow-up;Long term follow-up;o Infection complications.Infection complications.

State of art of State of art of indications in Iraqindications in Iraq::

Diagnostic lapDiagnostic lap: only contra-indication is : only contra-indication is failure to create pneumoperitoneum or failure to create pneumoperitoneum or medical contra-indication to medical contra-indication to pneumoperitoneum. Relative limitations are:pneumoperitoneum. Relative limitations are:

o Lack of tactile discrimination;Lack of tactile discrimination;o Bi-directional vision (angled scopes and tri-Bi-directional vision (angled scopes and tri-

dimensional in progress);dimensional in progress);o Assessment of retropeitoneal injuries in Assessment of retropeitoneal injuries in

traumatic cases (more or less like open traumatic cases (more or less like open laparotomy).laparotomy).


CholecystectomyCholecystectomy: definite advantage : definite advantage for laparoscopy. When to stop?for laparoscopy. When to stop?

o Lack of progress for 20-30 minutes;Lack of progress for 20-30 minutes;o Non clear anatomy;Non clear anatomy;o Suspected pathology in CBD with no Suspected pathology in CBD with no

available technology or expertise for available technology or expertise for laparoscopic exploration of CBD;laparoscopic exploration of CBD;

o Suspected iatrogenic injuries.Suspected iatrogenic injuries.


AppendicectomyAppendicectomy: Laparoscopy is : Laparoscopy is advantageous in:advantageous in:

o Obese;Obese;o Females with suspected diagnosis;Females with suspected diagnosis;o Athletes.Athletes.


VaricocelectomyVaricocelectomy: Laparoscopy has a definite : Laparoscopy has a definite advantage in bilateral recurrent cases.advantage in bilateral recurrent cases.

Inguinal herniaInguinal hernia: definite advantage in : definite advantage in recurrent hernia: relative rapid recovery is an recurrent hernia: relative rapid recovery is an advantage. Mesh repairs are usually tension advantage. Mesh repairs are usually tension free (transperitoneal or extraperitoneal) free (transperitoneal or extraperitoneal) expensed of the mesh and its fixation.expensed of the mesh and its fixation.

Female fertility problems:Female fertility problems: tubal patency, tubal patency, adhesolysis, ectopic pregnancy, endometriosis, adhesolysis, ectopic pregnancy, endometriosis, ovarian cysts and complications, fibroids, LAVHovarian cysts and complications, fibroids, LAVH

Advanced techniquesAdvanced techniques

o Hiatus hernia:Hiatus hernia: indications for indications for surgery did not change but probably surgery did not change but probably patients and internal medicine patients and internal medicine acceptance to laparoscopy is better. acceptance to laparoscopy is better. To surgeons, laparoscopy offers To surgeons, laparoscopy offers better exposure.better exposure.

Advanced techniquesAdvanced techniques::

o Peptic ulcerPeptic ulcer: indications again are not : indications again are not different: laparoscopy only decreases different: laparoscopy only decreases parietal complications which are not the parietal complications which are not the main disadvantages of surgical treatment of main disadvantages of surgical treatment of peptic ulcer on elective bases. However, peptic ulcer on elective bases. However, these complications are appreciable in these complications are appreciable in cases of perforated peptic ulcer which are cases of perforated peptic ulcer which are usually acute and over 50% do not need usually acute and over 50% do not need definitive ulcer surgery latter on: definitive ulcer surgery latter on: laparoscopy with proper technology may be laparoscopy with proper technology may be more useful in these conditions.more useful in these conditions.


o Splenectomy, nephrectomy: possible Splenectomy, nephrectomy: possible with small sized organs. However, with small sized organs. However, endo-GIA staplers may be needed endo-GIA staplers may be needed during laparoscopic management.during laparoscopic management.

o Laparoscopically assisted colectomy Laparoscopically assisted colectomy is possible with several advantage is possible with several advantage but however there is a theoretical but however there is a theoretical fear of port site metastases.fear of port site metastases.


o Laparoscopic exploration of CBD may Laparoscopic exploration of CBD may be very useful in operative surprise of be very useful in operative surprise of dilated CBD or the possibility of dilated CBD or the possibility of slipped stones during laparoscopic slipped stones during laparoscopic cholecystectomy or past history of cholecystectomy or past history of jaundice with no present evidence of jaundice with no present evidence of it. Otherwise, pre-operative ERCP it. Otherwise, pre-operative ERCP combined with laparoscopic combined with laparoscopic cholecystectomy may be as effective.cholecystectomy may be as effective.


o Laparoscopic subfascial ligation of Laparoscopic subfascial ligation of varicosities.varicosities.

o Laparoscopic face lift.Laparoscopic face lift.

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Indications and contraindications of Laparoscopy1