Campbell-Walsh Urology, 11th Edition

PART II

Basics of Urologic Surgery

10

Fundamentals of Laparoscopic and Robotic Urologic Surgery

Michael Ordon; Jaime Landman; Louis Eichel

Questions

  1. Absolute contraindications to laparoscopic surgery include all of the following EXCEPT:
  2. uncorrectable coagulopathy.
  3. hemodynamic instability.
  4. significant abdominal wall infection.
  5. suspected malignant ascites.
  6. extensive prior abdominal or pelvic surgery.
  7. Of the following, which is considered a relative contraindication to laparoscopic surgery?
  8. Generalized peritonitis
  9. Massive hemoperitoneum
  10. Intestinal obstruction with intention to treat
  11. Extensive prior abdominal or pelvic surgery
  12. Abdominal wall infection
  13. The best method of preoperative preparation for patients undergoing laparoscopic renal surgery is:
  14. a 3-day mechanical bowel preparation if an extraperitoneal or retroperitoneoscopic approach is anticipated.
  15. a mechanical bowel preparation and antibiotic preparation with neomycin and metronidazole.
  16. for most uncomplicated patients, a clear liquid diet and a light mechanical bowel preparation the day before surgery.
  17. both an antibiotic and 3-day mechanical bowel preparation in patients who have had previous abdominal surgery if one anticipates encountering dense intra-abdominal adhesions.
  18. intravenous antibiotics 1 hour before surgery.
  19. Which of the statements regarding pneumoperitoneum is TRUE?
  20. CO2as an insufflant can be dangerous because it can support combustion.
  21. CO2is most commonly used because it is insoluble in the blood.
  22. In patients with chronic respiratory disease, CO2is advantageous because it does not accumulate in the bloodstream.
  23. Argon gas would be an ideal insufflant because of its low cost and poor solubility in blood.
  24. Nitrous oxide has previously been used for insufflation; however, it is no longer routinely used because of the potential for intra-abdominal explosion.
  25. When a patient has had multiple prior abdominal surgeries and extensive adhesions are anticipated, which of the following access techniques is recommended for obtaining a pneumoperitoneum and access to the abdomen for laparoscopy?
  26. Closed technique with Veress needle
  27. Closed technique with blind trocar insertion
  28. Open-access technique
  29. Hand-port access
  30. EndoTip entry
  31. Which of the following port sites most often requires formal closure with a fascial and peritoneal suture?
  32. 5-mm nonbladed ports
  33. 5-mm bladed ports
  34. 10- to 12-mm bladed ports placed on the midclavicular line
  35. 10- to 12-mm nonbladed ports placed on the midclavicular line
  36. 10- to 12-mm nonbladed ports placed on the anterior axillary line
  37. Which of the following pneumoperitoneum pressures is associated with the least perturbation in cardiac parameters, that is, change in stroke volume?
  38. 12 mm Hg
  39. 15 mm Hg
  40. 18 mm Hg
  41. 21 mm Hg
  42. 24 mm Hg
  43. Which of the following physiologic effects has been noted with establishment of pneumoperitoneum?
  44. Increase in diaphragmatic motion
  45. Increase in disturbances of gastrointestinal motility
  46. Alkalosis
  47. Decrease in urinary output
  48. Increase in mesenteric vessel blood flow
  49. What is the most common intra-abdominal site of injury associated with laparoscopic surgery?
  50. Bowel injury
  51. Vascular injury
  52. Liver injury
  53. Splenic laceration
  54. Bladder injury
  55. What is a characteristic of a blunt trocar, compared with a bladed trocar?
  56. The blunt trocar requires formal closure of the port site regardless of its size.
  57. The blunt trocar takes less force to insert than the bladed trocar.
  58. The blunt trocar decreases the chance of injury to the epigastric vessels.
  59. The blunt trocar should only be placed in the midline.
  60. The blunt trocar eliminates possible trocar injury to the bowel.
  61. All of the following options for treatment of a gas embolism during laparoscopy are true EXCEPT:
  62. Hyperventilate the patient with 100% oxygen.
  63. Immediately cease insufflation.
  64. Place the patient in a head-down position.
  65. Advance a central venous line into the right side of the heart.
  66. Place the patient in a right lateral decubitus position with the left side up.
  67. Pneumomediastinum, pneumothorax, and pneumopericardium associated with laparoscopy are a result of:
  68. gas leaking along major blood vessels through congenital defects in the diaphragm.
  69. gas passing through secondary enlargement of openings in the diaphragm.
  70. diffusion of gas across the peritoneum and diaphragm.
  71. a and b.
  72. a and c.
  73. If during insufflation of the abdomen the Veress needle is determined to have been placed into the iliac artery, which of the following is the best course of action?
  74. Remove the Veress needle and proceed to open the abdomen.
  75. Remove the Veress needle and then proceed with insufflating at a different location.
  76. Leave the Veress needle in place and open the abdomen.
  77. Leave the Veress needle in place and proceed with insufflation of the abdomen at a different location.
  78. Call for a vascular surgery consult.
  79. What is the best management option if trocar injury to the iliac artery should occur during the placement of the first trocar?
  80. Remove the trocar and open the abdomen immediately.
  81. Remove the trocar immediately and proceed with re-insufflation of the abdomen and placement of the trocar at an alternate site.
  82. Leave the trocar in place, consult a vascular surgeon, and convert to open laparotomy.
  83. Leave the trocar in place and proceed with insufflation of the abdomen and placement of another port at an alternate site.
  84. Remove the obturator and immediately flush the port with fibrin glue.
  85. Thermal bowel injury during laparoscopy can occur as a result of all of the following EXCEPT:
  86. capacitive coupling.
  87. insulation failure.
  88. inappropriate direct activation.
  89. electrode resistance.
  90. coupling to another instrument.
  91. When a bladder injury is diagnosed postoperatively after a laparoscopic procedure, what is the best treatment?
  92. Transurethral indwelling Foley catheter if it is an intraperitoneal injury of the bladder
  93. Open repair if it is an extraperitoneal injury of the bladder
  94. Laparoscopic or open repair if it is an intraperitoneal injury to the bladder
  95. Laparoscopic repair if it is an extraperitoneal injury to the bladder
  96. Transurethral injection of fibrin glue into the bladder injury site if it is an extraperitoneal injury to the bladder
  97. Hypercarbia during laparoscopy may be related to all of the following EXCEPT:
  98. severe chronic respiratory disease.
  99. subcutaneous emphysema.
  100. increased insufflation pressures.
  101. prolonged operative time.
  102. radical nephrectomy.
  103. Possible advantages of retroperitoneal laparoscopy include all of the following EXCEPT:
  104. less need for lysis of adhesions.
  105. decreased risk of paralytic ileus.
  106. decreased risk of port-site hernias.
  107. direct rapid access to the renal hilum.
  108. technically easier to learn.
  109. After extraperitoneal pelvic lymph node dissection, the incidence of which one of the following is higher than with transperitoneal pelvic node dissection?
  110. Urinoma
  111. Lymphocele
  112. Bowel injury
  113. Laparoscopic repair if it is an extraperitoneal injury to the bladder
  114. Shoulder/hip pain
  115. All of the following instruments might be part of a hemorrhage control tray EXCEPT:
  116. laparoscopic needle drivers.
  117. laparoscopic Satinsky clamp and accompanying trocar.
  118. Lapra-Ty clip applier and 6-inch length of 3-0 absorbable suture.
  119. hemostatic agents (fibrin glue, gelatin matrix thrombin, etc.) plus laparoscopic applicators.
  120. laparoscopic renal biopsy forceps.
  121. Which of the following hemostatic agents requires a 20-minute setup time before use?
  122. Tisseel
  123. FloSeal
  124. CrossSeal
  125. BioGlue
  126. CoSeal
  127. Which of the following relationships is true for port placement for laparoscopic suturing?
  128. The angle produced by the horizontal plane and the instruments should be greater than 55 degrees and the angle between the needle drivers should be less than 25 degrees.
  129. The angle produced by the horizontal plane and the instruments should be less than 55 degrees and the angle between the needle drivers should be between 25 and 45 degrees.
  130. The angle produced by the horizontal plane and the instruments should be greater than 55 degrees and the angle between the needle drivers should be greater than 45 degrees.
  131. The angle produced by the horizontal plane and the instruments should be less than 55 degrees and the angle between the needle drivers should be less than 25 degrees.
  132. The angle produced by the horizontal plane and the instruments should be greater than 55 degrees and the angle between the needle drivers should be between 25 and 45 degrees.
  133. During a procedure using the Da Vinci Robotic System, the robot malfunctions and one of the grasping forceps is closed on a vital structure. The system is completely unresponsive. The appropriate action to safely disengage the instrument from the vital structure is to:
  134. use the surgeon's console to override the system and robotically disengage the grasper.
  135. remove the robotic instrument from the robotic arm.
  136. use the sterile Allen wrench provided by the company to manually disengage the instrument and then remove it from the robotic arm.
  137. use a handheld laparoscopic instrument to pry open the jaws of the robotic instrument.
  138. unplug the surgeon's console and robotic tower, plug them back in, and restart the system.
  139. After placement of the Veress needle, insufflation should never be initiated unless all of the following signs for proper peritoneal entry are confirmed EXCEPT?
  140. Negative aspiration
  141. Easy irrigation of saline
  142. Negative pressure test
  143. Positive drop test
  144. Normal advancement test
  145. Carbon dioxide is the most commonly used insufflant because it is:
  146. noncombustible.
  147. rapidly absorbed.
  148. inexpensive.
  149. colorless.
  150. all of the above.
  151. Helium is a useful insufflant in patients with:
  152. coronary artery disease.
  153. peripheral vascular disease.
  154. pulmonary disease.
  155. inflammatory bowel disease.
  156. chronic kidney disease.
  157. Which of the following are signs of bowel insufflation with the Veress needle?
  158. Asymmetrical abdominal distention
  159. Flatus
  160. High pressures reached after a large amount of CO2is insufflated
  161. a and c
  162. a and b
  163. The diagnosis of air embolism is usually made by the anesthesiologist based on an initial abrupt:
  164. increase in end-tidal CO2.
  165. decrease in end-tidal CO2.
  166. increase in oxygen saturation.
  167. increase in mean arterial pressure.
  168. decrease in airway pressures.
  169. Laparoscopic virtual reality trainers have been shown to:
  170. increase the operating time and improve the operative performance of surgical trainees with limited laparoscopic experience when compared with no training or with box-trainer training.
  171. decrease the operating time and improve the operative performance of surgical trainees with limited laparoscopic experience when compared with no training or with box-trainer training.
  172. decrease the operating time and improve the operative performance of surgical trainees with extensive laparoscopic experience when compared with no training or with box-trainer training.
  173. a and b.
  174. a and c.
  175. All of the following increase the risk of developing rhabdomyolysis from flank pressure when the patient is positioned in the modified flank position EXCEPT:
  176. BMI ≥ 25.
  177. elevation of the kidney rest.
  178. age < 45 years.
  179. male gender.
  180. full table flexion.
  181. When using a laparoscopic stapling device, the 2.0-mm or 2.5-mm staple cartridges are preferred for:
  182. bowel.
  183. bladder.
  184. ureter.
  185. vascular (renal artery or vein).
  186. a and d.
  187. All of the following represent options for port site fascial closure EXCEPT:
  188. retractors and direct vision.
  189. Endo Stitch.
  190. Carter-Thomason needlepoint suture passer.
  191. disposable Endo Close suture carrier.
  192. angiocatheter technique.
  193. The basic principles of Hem-o-Lok clip placement include all of the following EXCEPT:
  194. incomplete circumferential dissection of the vessel.
  195. visualization of the curved tip of the clip around and beyond the vessel.
  196. confirmation of the tactile snap when the clip engages.
  197. during transaction of vessels, only a partial division is performed initially to confirm hemostasis before complete transaction.
  198. no cross clipping.
  199. Balloon trocars are advantageous because they can help reduce the risk of:
  200. air embolism.
  201. alkalosis.
  202. subcutaneous emphysema.
  203. hypothermia.
  204. all of the above.
  205. Certain precautions must be followed during monopolar electrosurgery to avoid local or distant transmitted thermal injury, including:
  206. checking the insulation of the electrosurgical instrument carefully for damage.
  207. not activating the electrosurgical probe unless the metal part is in complete view.
  208. not activating the probe unless it is in direct contact with the tissue to be incised.
  209. never using a metal trocar in conjunction with an outer plastic retaining ring.
  210. all of the above.

Answers

  1. e. Extensive prior abdominal or pelvic surgeryAbsolute contraindications for laparoscopic surgery include uncorrectable coagulopathy, intestinal obstruction, abdominal wall infection, massive hemoperitoneum or hemoretroperitoneum, generalized peritonitis or retroperitoneal abscess, and suspected malignant ascites.
  2. d. Extensive prior abdominal or pelvic surgery.When extensive intra-abdominal or pelvic adhesions are suspected, close attention must be given to access into the abdomen whether this is by Veress needle (Ethicon Endo-Surgery, Blue Ash, OH) or some open-access technique. Alternatively, in these patients, a retroperitoneal approach may be preferable to a transperitoneal approach, but this is only a relative contraindication to performing laparoscopic surgery. All of the other options listed are absolute contraindications to laparoscopic surgery.
  3. e. Intravenous antibiotics 1 hour before surgery.For extraperitoneoscopy and retroperitoneoscopy, no bowel preparation is necessary. Similarly, for transperitoneal laparoscopic/robotic procedures notinvolving the use of bowel segments for urinary tract reconstruction, a mechanical bowel preparation is not necessary. A recent large-scale propensity score-matched analysis demonstrated no benefit for mechanical bowel preparation in operative time, postoperative stay, or overall complications for patients undergoing laparoscopic nephrectomy (Sugihara et al, 2013).*
  4. e. Nitrous oxide has previously been used for insufflation; however, it is no longer routinely used because of the potential for intra-abdominal explosion.Most commonly, CO2 is used as the insufflant because it does not support combustion and is very soluble in blood. However, in patients with chronic respiratory disease CO2 may accumulate in the bloodstream to dangerous levels. In these patients, helium may be used for insufflation once the initial pneumoperitoneum has been established with CO2. The drawback of helium is that, like air, it is much less soluble in the blood than CO2. However, its use averts problems with hypercarbia. Other gases that were once used for insufflation, including room air, oxygen, and nitrous oxide, are no longer routinely used because of their potential side effects, such as air embolus or intra-abdominal explosion and potential to support combustion.
  5. c. Open-access technique.A pneumoperitoneum can be more easily and, in one's early experience, more safely established using an open technique, especially in patients with multiple prior surgeries, who are at high risk for intra-abdominal adhesions. However, its use involves making a larger incision and increases the chances of port-site gas leakage during the procedure. Studies in general surgery have shown the open technique to be as efficient as a closed approach.
  6. c. 10- to 12-mm bladed ports placed on the midclavicular line.All bladed port sites that are greater than 5 mm should be formally closed, independent of location.
  7. a. 12 mm Hg.Recent studies support a pneumoperitoneum pressure of 12 mm Hg, because this results in no perturbation in cardiac parameters, that is, no change in stroke volume, versus a pressure of 15 mm Hg. Working at lower pneumoperitoneum pressures has also been found to reduce postoperative pain. Also, a marked reduction in oliguria has been associated with working at 10 mm Hg pressure.
  8. d. Decrease in urinary output.Because of increased intra-abdominal pressure from the pneumoperitoneum, diaphragmatic motion is limited. Laparoscopic surgery causes less significant disturbances of the gastrointestinal motility pattern compared with open surgery. Insufflation with CO2 results in variable amounts of gas absorption, thereby raising the Pco2 in the blood and creating an acidosis. Increased intra-abdominal pressure was found to be associated with a significant decrease in urinary output secondary to decreased blood flow to the renal cortex with an associated decrease in renal vein blood flow of up to 90% at 15 mm Hg.
  9. b. Vascular injuryThe most common site of injury during laparoscopic surgery, in reports in the literature, is vascular in origin, occurring in 2.8% of patients, followed by bowel injury at 1.1%. The most often injured intra-abdominal organ was the bowel, at an incidence of 1.2%.
  10. c. The blunt trocar decreases the chance of injury to the epigastric vessels.The use of only blunt trocars decreases the chance of injury to the epigastric vessels by fivefold.
  11. e. Place the patient in a right lateral decubitus position with the left side up.The treatment for a suspected gas embolism is immediate cessation of insufflation and prompt desufflation of the peritoneal cavity. The patient is turned into a left lateral decubitus head-down position (i.e., right side up) to minimize right ventricular outflow problems. The patient is hyperventilated with 100% oxygen. Advancement of a central venous line into the right side of the heart with subsequent attempts to aspirate the gas may rarely be helpful. Use of hyperbaric oxygen and cardiopulmonary bypass have also been reported.
  12. d. a and b.Gas leaking along major blood vessels through congenital defects or secondary enlargement of openings in the diaphragm may lead to pneumomediastinum, pneumopericardium, and pneumothorax.
  13. d. Leave the Veress needle in place and proceed with insufflation of the abdomen at a different location.If vascular injury should occur with the Veress needle, the needle should be left in place to identify the area of injury, and insufflation of the abdomen can be re-performed at an alternate site and then the laparoscope inserted to identify the area of injury and to observe this as the Veress needle is removed to control any hemorrhage that may occur from the site.
  14. c. Leave the trocar in place, consult a vascular surgeon, and convert to open laparotomy.A trocar injury to a major arterial vessel is a potentially life-threatening complication. The trocar should remain in place to tamponade the bleeding and also identify the area of injury once the abdomen is opened. The patient's blood should be typed and crossmatched, and immediate laparotomy should be performed and the site of vascular injury identified. A vascular surgery consult may be needed.
  15. d. Electrode resistance.Electrosurgically induced thermal injury may occur through of one of four mechanisms: inappropriate direct activation; coupling to another instrument; capacitive coupling; and insulation failure.
  16. c. Laparoscopic or open repair if it is an intraperitoneal injury to the bladder.When bladder injury is diagnosed postoperatively, the surgeon must determine whether the perforation is extraperitoneal or intraperitoneal. Extraperitoneal injury, without any complicating additional problems, may be treated by simple placement of a transurethral indwelling Foley catheter. Intraperitoneal injury is an indication for subsequent laparoscopic or open repair.
  17. e. Radical nephrectomy.The potential for developing hypercarbia exists during both transperitoneal and preperitoneal laparoscopic procedures. Conceivably, this assumes greater importance in patients with preexisting airway and cardiovascular compliance. Vigilant perioperative anesthetic management is essential to prevent the development of potential complications related to CO2 buildup. A rise in end-tidal CO2 should prompt the anesthesiologist to adjust the respiratory rate and tidal volume to enhance CO2 elimination. Simultaneously, the insufflation pressure of CO2 should be decreased by the surgeon or, if need be, the operation should be halted and the abdomen desufflated until the end-tidal CO2 returns to an acceptable level.
  18. e. Technically easier to learn.Retroperitoneoscopy is associated with unique anatomic orientation and a relatively restricted initial working area compared with transperitoneal laparoscopy. This results in a steeper learning curve.
  19. b. Lymphocele.Absence of the peritoneal absorptive surface after extraperitoneoscopic lymphadenectomy may increase the risk of development of postoperative lymphocele
  20. e. laparoscopic renal biopsy forceps.The contents of a hemorrhage tray for laparoscopic surgery include the following:
  • Laparoscopic Satinsky clamp (Medline Industries Inc., Mundelein, IL)
  • 10-mm suction/irrigation tip
  • Endo Stitch device with a 4-0 absorbable suture
  • Lapra-Ty clip (Ethicon US, LLC, CA) applier and a packet of Lapra-Ty clips
  • 6-inch length of 4-0 vascular suture on an SH needle with a Lapra-Ty clip preplaced on the end
  • Two laparoscopic needle drivers
  • Topical hemostatic agent of choice
  1. a. Tisseel.Tisseel (Baxter, Glendale, CA) is a form of fibrin glue containing fibrinogen, calcium chloride, aprotinin, and thrombin. It is useful as a topical hemostatic agent as well as a tissue glue, but it has a 20-minute setup time and thus must be prepared well in advance of potential use.
  2. b. The angle produced by the horizontal plane and the instruments should be less than 55 degrees and the angle between the needle drivers should be between 25 and 45 degrees.Frede and colleagues performed an in vitro experiment performing laparoscopic suturing while varying trocar relationship to the horizontal plane and the distance between the two instrument trocars. They found that suturing was easiest when the angle between the horizontal plane and the instruments was less than 55 degrees and the angle between the two instruments was between 25 and 45 degrees (Frede et al, 1999).*
  3. c. Use the sterile Allen wrench provided by the company to manually disengage the instrument and then remove it from the robotic arm.In the event of a system failure of the da Vinci Robotic System (Intuitive Surgical, Sunnyvale, CA) during which the robotic arms are rendered nonfunctional, instrument jaws can be manually opened using a sterile Allen wrench provided by the company for this purpose.
  4. c. Negative pressure test.Several tests can be performed in an attempt to confirm proper placement of the Veress needle within the peritoneal cavity before insufflation to reduce the risk of insufflation related complications. These tests include: the aspiration/irrigation/aspiration test, the advancement test, and the drop test. Insufflation should never be initiated unless all of the signs for proper peritoneal entry (negative aspiration, easy irrigation of saline, negative aspiration of saline, positive drop test, and normal advancement test) have been confirmed.
  5. e. All of the above.CO2 is the most commonly used insufflant for laparoscopic surgery and is favored by most laparoscopists thanks to its properties (colorless, noncombustible, very soluble in blood, and inexpensive).
  6. c. Pulmonary disease.Helium is an inert and noncombustible insufflant. Initial studies performed in various animal models showed favorable effects on arterial partial pressure of CO2 and pH with no evidence of hypercarbia (Fitzgerald et al, 1992; Leighton et al, 1993; Rademaker et al, 1995). These results were corroborated by clinical studies (Bongard et al, 1991; Fitzgerald et al, 1992; Leighton et al, 1993; Neuberger et al, 1994; Rademaker et al, 1995; Jacobi et al, 1997). Therefore, helium is particularly useful for the patient with pulmonary disease in whom hypercarbia would be poorly tolerated.
  7. e, a, and b.If entry into the bowel is not recognized at the time of irrigation and aspiration through the Veress needle, then the surgeon may insufflate the small or large bowel. The first sign of this problem is asymmetrical abdominal distention followed by flatus and insufflation of only a small amount of CO2 (< 2 L) before high pressures are reached.
  8. a. Increase in end-tidal CO2.The diagnosis of CO2 gas embolism is usually made by the anesthesiologist based on an abrupt increase of end-tidal CO2 accompanied by a sudden decline in oxygen saturation and then a marked decrease in end-tidal CO2. Sometimes, a "millwheel" precordial murmur can be auscultated. In addition, the anesthesiologist may notice foaming of a blood sample, if drawn, owing to the presence of insufflated CO2.
  9. b. Decrease the operating time and improve the operative performance of surgical trainees with limited laparoscopic experience when compared with no training or with box-trainer training.Virtual reality (VR) trainers are computer-based simulators that offer the opportunity to practice laparoscopic and robotic skills through specific tasks, as well as whole procedures. VR trainers have been shown to improve the skills of trainees helping to prepare them for better performance during live surgery (Seymour et al, 2002; Lucas et al, 2008). A recent systematic review demonstrated that VR training appears to decrease the operating time and improve the operative performance of surgical trainees with limited laparoscopic experience when compared with no training or with box-trainer training (Nagendran et al, 2013).
  10. c. Age < 45 years.Male patients with a BMI ≥ 25 undergoing laparoscopic surgery in the lateral position with the kidney rest elevated and the table completely flexed are at highest risk of developing rhabdomyolysis due to flank pressure.
  11. d. Vascular (renal artery or vein).Various stapling devices are available for tissue occlusion and division. Each staple load cartridge is color-coded depending on the size of the staples: 2.0-mm staples (gray) or 2.5-mm staples (white) are preferred for vascular (renal vein or renal artery) stapling, whereas 3.8-mm (blue) and 4.8-mm (green) staples are used in thicker tissues (ureter, bowel, bladder).
  12. b. Endo Stitch.The Endo Stitch (Covidien, Mansfield, MA) device is an innovative, disposable, 10-mm instrument that facilitates laparoscopic suture placement and knot tying, not port site closure.
  13. a. Incomplete circumferential dissection of the vessel.The basic principles of Hem-o-Lok (Teleflex, Morrisville, NC) placement include the following:
  • Complete circumferential dissection of the vessel
  • Visualization of the curved tip of the clip around and beyond the vessel, often with curved end of the clip placed between artery and vein
  • Confirmation of the tactile snap when the clip engages
  • No cross clipping
  • Not squeezing clip handles too hard (compared with the application of metal clips)
  • Careful removal of the applier after application given; the tips are sharp and can cause a laceration of nearby vessels (e.g., renal vein)
  • During transection of vessels only a partial division is performed initially to confirm hemostasis before complete transection
  • Minimum of two clips placed on the patient side of the renal hilar vessel
  1. c. Subcutaneous emphysema. Once the balloon cannula is positioned in the abdominal cavity, the balloon is inflated; the cannula is pulled upward until the balloon is snug on the underside of the abdominal wall. Next, the soft foam or rubber collar on the outside surface of the cannula is slid down until it is snug on the skin and locked in place. This process creates an excellent seal, precluding gas leakage and subcutaneous emphysema.
  2. e. All of the above.Several actions can be taken by the surgeon to lessen the risks of a thermal complication. First, electrosurgical instruments must be carefully inspected before use for any "breaks" in the insulation; if these are found, the instrument must be sent for recoating. Second, electrosurgical instruments should never be left untended within the abdomen; when not in use they must be removed from the abdomen. Third, only the primary surgeon should control electrode activation. Fourth, isolation of the area to be cauterized from the surrounding tissues, as well as use of bipolar electrocautery, reduces the risk of thermal spread and injury to other tissues. Fifth, the electrosurgical device should never be activated unless the entire extent of the metal portion of the instrument is in view. Sixth, problems of capacitive coupling can be precluded by not creating a situation in which a mixture of conducting and nonconducting elements are used by the surgeon (e.g., metal trocars combined with plastic retainers). Last, an active electrode monitoring system (Encision, Boulder, CO) is extremely helpful, as any sudden break in the insulation of the electrosurgical instrument results in immediate shutdown of the electrosurgical current, thereby precluding an electrosurgical injury.

Chapter review

  1. Patients with massive ascites have an increased incidence of bowel injury when trocars are placed because of the closer proximity of the bowel loops to the anterior abdominal wall.
  2. The Veress needle is commonly placed at the superior border of the umbilicus; there is a potential risk of injury to the left common iliac vessels, aorta, and vena cava.
  3. The signs of proper peritoneal entry using the Veress needle include negative aspiration, easy irrigation of saline, negative aspiration of saline, positive drop test, and normal advancement test.
  4. When using a stapler, the tissue must be properly situated between the markers before the cartridge is fired. Otherwise, a portion of the tissue will not be encompassed by the stapler. A stapler should not be fired across any previously placed clips.
  5. Before port removal is initiated, the operative site and the intra-abdominal entry sites of each cannula should be carefully inspected for bleeding with the intra-abdominal pressure lowered to 5 mm Hg.
  6. Patients with chronic obstructive pulmonary disease (COPD) may not be able to compensate for the absorbed CO2by increased ventilation and are at increased risk for hypercarbia as long as 2 to 3 hours after the procedure.
  7. Nitrous oxide insufflation reduces cardiac output and increases mean arterial pressure, heart rate, and central venous pressure. It also supports combustion.
  8. In patients with severe COPD, one should consider using helium as an alternative for insufflation.
  9. A drawback of helium for insufflation is that it is much less soluble in blood than CO2. Helium may be associated with a higher risk of gas embolism because of its lower blood solubility, and thus the initial pneumoperitoneum should be established with CO2and then the insufflation should be maintained with helium.
  10. Intra-abdominal pressures during laparoscopy should not be allowed to exceed 20 mm Hg over extended periods of time, and a working pressure of 10 to 12 mm Hg is recommended.
  11. Increased intra-abdominal pressures may artificially elevate central venous pressure readings; thus if it is critical to know right atrial filling pressures, a Swan-Ganz catheter (Edwards Lifesciences, Irvine, CA) should be placed.
  12. During laparoscopy, diaphragmatic motion is limited and functional reserve capacity is decreased. There is a significant decrease in urinary output and decreased blood flow to mesenteric vessels as well as other abdominal organs, including liver, pancreas, stomach, spleen, and small and large bowel.
  13. Excessive intra-abdominal pressure usually presents as an increase in ventilation pressure noted by the anesthesiologist.
  14. During removal of laparoscopic ports and desufflation, bowel and omentum may be entrapped at one of the port sites.
  15. Absolute contraindications for laparoscopic surgery include uncorrectable coagulopathy, intestinal obstruction, abdominal wall infection, massive hemoperitoneum or hemoretroperitoneum, generalized peritonitis or retroperitoneal abscess, and suspected malignant ascites.
  16. Increased intra-abdominal pressure is associated with a significant decrease in urinary output secondary to decreased blood flow to the renal cortex with an associated decrease in renal vein blood flow of as high as 90% at 15 mm Hg.

* Sources referenced can be found in Campbell-Walsh Urology, 11th Edition, on the Expert Consult website.

* Sources referenced can be found in Campbell-Walsh Urology, 11th Edition, on the Expert Consult website.м