Abdominal Access in Open and Laparoscopic Surgery
Access, exposure, and judgment are key elements in the design
of a successful operation. In the past, making long incisions
was the gold standard of gaining access into the abdominal and
thoracic cavities. Since the introduction of videoscopic technology,
long incisions have been replaced by trocars. In this chapter
we will give an overview of three major methods of gaining access
for abdominal surgery: (1) intraabdominal access, (2) intraluminal
access, and (3) extraperitoneal access. Subsequent chapters
will concentrate on various methods of open and laparoscopic surgery.
II. INTRAABDOMINAL ACCESS
Traditionally surgeons have gained access into the abdominal cavity
via the anterior abdominal wall. In the age of minimally invasive
surgery, incisions have been replaced by multiple trocar insertions
and direct vision and tactile sensation by videoscopy. As more
experience is gained, additional complicated procedures are being
performed with the aid of the laparoscope combined with the technique
of miniincision. In general, the appropriately placed accesstrocar(s)
and/or miniincision(s)facilitate anatomical exposure and improve
vision, minimizing postoperative complications.
Surgeons universally agree that adequate exposure is the most
important technical aspect of an operation. In open procedures,
exposure is best obtained by the assistant and an ever expanding
traditional instrumentation. In conventional laparoscopic surgery,
pneumoperitoneum aids the exposure by displacing abdominal contents
and abdominal wall elevation. Specially designed laparoscopic
retractors are useful in achieving needed exposure. These mechanical
retractors are far from ideal. They are often difficult to employ
or fail to adjust to the contour of the abdominal structures.
A well-designed retractor is usually one that mimics those used
in open surgery, including the hands of the assistants. Current
instrumentation employed in videoscopic surgery should be considered
a first-generation development. Technology is expected to develop,
produce, and distribute a second generation of minimally invasive
instruments more specifically designed to meet the needs for adequate
In open surgery, a midline vertical or transverse incision enables
the surgeon to perform almost any abdominal procedure. These
incisions carry potential morbidity associated with pain and large
scars. As a result, surgeons have used smaller incisions for
organ-specific procedures when there is a high degree of certainty.
For example, subcostal incisions are commonly used for splenectomy
and cholecystectomy, and McBurney's or Rocky-Davis incisions for
appendectomy. In those circumstances where a misdiagnosis is
encountered, the surgeon must be knowledgeable as to how the incision
can be extended. This requires a basic knowledge of the musculoaponeurotic
structures of the anterior abdominal wall. A separate incision
may be required if the surgeon needs better exposure.
In minimally invasive surgery, laparoscopy may facilitate the
diagnosis of intraabdominal pathology. Most trocar placements
in conventional laparoscopic surgery are located around the pathology,
that is, the organ targeted for the operation. To remote the
organ from the abdomen may necessitate miniincisions near the
targeted structure to minimize air leak and to facilitate the
extraction. Occasionally, a surgeon will encounter a situation
where the procedure must be converted from a laparoscopic approach
to open surgery. This decision is the earmark of a mature surgeon.
Under these circumstances, an adequate midline or transverse
incision to gain ample access to and exposure of the abdominal
cavity is utilized.
III. INTRALUMINAL ACCESS
Besides incisions and trocars, another diagnostic and therapeutic
method for gaining access to the abdominal structures is endoscopy.
It was not utilized by many surgeons in the past because of
lack of training or because they relegated their role to the gastroenterologist.
With the development of the flexible video-endoscope, surgeons
can easily perform diagnostic and therapeutic interventions via
intraluminal access with minimal patient discomfort. Surgeons
who perform their own endoscopies will likely have more insight
into their patients' disease. Performing esophageal and colorectal
surgery based upon the endoscopic findings of someone else is
less than ideal and places the surgeon in a precarious position.
We now know that early gastrointestinal malignancy can be treated with endoscopic excision (Figure 1. 1). Palliative treatment for advanced malignancy can also be performed with endoscopic techniques, for example, (1) balloon dilatation and/or intraluminal stenting for biliary or gastrointestinal malignant obstruction and (2) laser therapy for esophageal tumor. Benign diseases that have been successfully treated by endoscopic interventions include gastrointestinal hemorrhage, bile duct obstruction (secondary to stones or stricture), gastrointestinal obstruction resulting from acid or caustic substance ingestion, esophageal motility disorders (achalasia, diffuse esophageal spasm, scleroderma), peptic ulcer disease, gastroesophageal reflux, colonic volvulus (Figure 1. 2), and pseudoobstruction (Ogilvie's syndrome). Foreign bodies in the gastrointestinal tract can frequently be removed using intraluminal endoscopy, thereby avoiding open surgery (Figure 1. 3).
When combined with open or laparoscopic surgery, the fiber-optic
endoscope can also facilitate the exposure of the operating field.
One such application is the placement of a flexible sigmoidoscope
in the rectum to transilluminate a Hartman's pouch during a colostomy
take-down. This technique allows the surgeon to use the light
as a guide with the endoscope in the bowel lumen as a handle for
manipulation during dissection. Surgeons have used laparoscopy
to monitor colonoscopic polypectomy. 1 Others have used a flexible
gastroscope to identify duodenal microgastrinomas. Payne and
colleagues have used a flexible gastroscope to identify and monitor
the laparoscopic removal of small gastric leiomyomas. 2 Another
therapeutic use of the endoscope is to perform laparoscopic antegrade
sphincterotomy in the management of choledocholithiasis. 3 This
technique expands the ability of the surgeon to provide definitive
management of both cholelithiasis and choledocholithiasis without
additional preoperative endoscopic procedures.
The technique of intraluminal access that has replaced open surgery
is the placement of gastric enteral access for nutritional support.
In 1981, Gauderer and Ponsky used the fiber-optic endoscope
to transilluminate the stomach for percutaneous endoscopic gastrostomy
(PEG). 4 Another similar technique by Russell and associates
has added to the progressively decreasing utilization of open
gastrostomy. 5 Russell paved the way for further expansion of
intraluminal access in laparoscopic surgery.
Recently, surgeons have investigated the use of the flexible gastroscope
to inflate the stomach to expose an operating field in the excision
of gastric cancer. 6 With this intraluminal technique, the stomach
is first inflated with the help of a flexible gastroscope. The
stomach is then transilluminated for the laparoscopic surgeon
to place trocars directly through the abdominal wall into the
stomach. Additional insufflation of the stomach can be achieved
by connecting the gas port of the trocar to an insufflator.
A rigid laparoscope is placed into the stomach via the trocar
for intraluminal endoscopy. Once the lesion is identified, additional
trocars can be placed into the stomach for surgical instruments
(Figure 1. 4). Filipi and associates have used the intraluminal
approach to manage gastric bezoars. 7 In their technique, multiple
percutaneous endoscopic gastrostomies were used as channels for
access into the stomach. The use of intraluminal techniques
will undoubtedly be used to manage gastrointestinal and biliary
disease without traditional open surgery.
IV. EXTRAPERITONEAL ACCESS
The extraperitoneal access to intraabdominal structures includes
both the retroperitoneal and properitoneal approaches. Surgeons
have long recognized that certain abdominal structures, (abdominal
aorta, kidneys, and adrenal glands) can be accessed extraperitoneally
with better exposure than transperitoneally. Report of a prospective
randomized trial comparing a transabdominal versus a retroperitoneal
approach for abdominal aortic surgery has shown that the retroperitoneal
approach resulted in shorter duration in both the intensive care
unit and hospital with subsequent lower hospitalization costs.
8 Some vascular surgeons routinely perform aortic reconstructive
surgery via the retroperitoneal approach in patients who have
significant cardiopulmonary disease or who have had previous abdominal
surgery (Table 1. 1). But there are disadvantages that prohibit
the wider acceptance of the retroperitoneal approach for aortic
reconstructive surgery; for instance, access to the right renal
and iliac arteries is difficult.
Adrenalectomy represents another use of the extraperitoneal approach
to intraabdominal organs. Fahey and coworkers have successfully
completed 47 out of 51 consecutive adrenalectomies via the extraperitoneal
approach. The anterior approach was employed in three out of
the four unsuccessful cases because of intraabdominal metastasis.
9 The retroperitoneal exposure for spine surgery results in less
pain and the length of postoperative ileus.
Surgeons have used the properitoneal approach to perform laparoscopic
herniorrhaphy. 10 The idea of properitoneal approach for hernia
repair is not new: Cheatle in 1920 and Henry in 1936 used the
properitoneal approach to repair inguinal and femoral hernias.
11,12 One major difference between Cheatle-Henry repair and modern
laparoscopic repair is the introduction of synthetic material
to repair the floor of the inguinal canal. Proponents of such
an approach reason that this will avoid entering the abdomen during
hernia repair, thereby reducing the risk of injuring intraabdominal
organs and avoiding adhesions. The ideal candidates for laparoscopic
herniorrhaphy are patients with bilateral inguinal defects, recurrent
hernia, and simultaneous hernia repair in conjunction with other
New developments in balloon technology potentially will enable
surgeons to perform retroperitoneal aortic surgery and spine surgery.
13,14 The balloon-dissection technique involves the initial placement
of a small extraperitoneal incision for the insertion of the dissecting
balloon. The balloon is then inflated and a laparoscope placed
into the balloon dissector to create a working space in the retroperitoneum
under direct laparoscopic guidance (Figure 1. 5). Later, the
dissecting balloon is removed and the retroperitoneal exposure
is enlarged using either pneumoperitoneum or abdominal-wall retractor.
Extraperitoneal procedures performed with open and laparoscopic
techniques are listed in Table 1. 2
In the field of minimally invasive surgery, procedures that are
routinely performed via a long incision may be replaced by access
ports or miniincisions. The principles that have been developed
and used in past years of open surgery to obtain access and exposure
have not changed. In the following chapters, the various techniques
of access into the abdomen, ranging from open to laparoscopic
surgery will be discussed. An exciting phase of the evolution
of laparoscopic surgery is the development of a gasless technique
for the creation of the operating field, which has shown considerable
promise and will be reviewed in detail in Chapters 7-10.
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3. Depaulo AL, Hashiba K, Bafutto M, et al.: "Laparoscopic antegrade sphincteromy." Surg Laparosc Endosc 1993, 3:157-160.
4. Gauderer MWL, Ponsky JL: "A simplified technique for constructing a tube feeding gastrostomy." Surg Gynecol Obstet 1981, 152:83-85.
5. Russell TR, Brotman M, Norris F: "Percutaneous gastrostomya new simplified and cost-effective technique." Am J Surg 1984, 132-137.
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8. Sicard GA, Reilly JM, Rubin BG, et al.: "Transabdominal versus retroperitoneal incision for abdominal aortic surgery: Report of a prospective randomized trial." J Vasc Surg 1995, 21:174-183.
9. Fahey TJ 3rd, Reeve TS, Delbridge L: "Adrenalectomy: expanded indications for the extraperitoneal approach." Aust N Z J Surg 1994, 64:494-497.
10. Phillips EH, Carroll BJ, Fallas MJ: "Laparoscopic
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Surg Endosc 1993, 7:159-162.
11. Cheatle, GL: "An operation for the radical cure of
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12. Henry, AK: "Operation for femoral hernia by a midline
extraperitoneal approach." Lancet 1936, 1:531-533.
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