Abdominal Access in Open and Laparoscopic Surgery
  • ISBN 0-471-13352-3
  • Auguest 1996
  • 194 pages
  • Hardcover

Abdominal Access in Open and Laparoscopic Surgery


Description | Table of Contents | List of Contributors

Edited by:
Edmund K.M. Tsoi, M.D.
    University of California-Davis, East Bay, Department of Surgery, Oakland, CA

Claude H. Organ, Jr., M.D
    University of California-Davis, East Bay, Department of Surgery, Oakland, CA


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 Since the introduction of videoscopic technology, long incisions have been replaced by trocars.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.


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 In the age of minimally invasive surgery, incisions have been replaced by multiple trocar insertions and direct vision and tactile sensation by videoscopy.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 access—trocar(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 surgical exposure.

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.


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.


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 laparoscopic procedures.

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.


1. Averbach M, Cohen RV, de Barros MV, et al.: "Laparoscopy assisted colonoscopic polypectomy." Surg Laparosc & Endosc 1995, 5:137-138.

2. Payne WG, Murphy CG, Grossbard LJ: "Combined laparoscopic and endoscopic approach to resection of gastric leiomyoma." J. Laparoendosc Surg 1995, 5:119-122.

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 gastrostomy—a new simplified and cost-effective technique." Am J Surg 1984, 132-137.

6. Ohashi S: "Laparoscopic intraluminal (intragastric) surgery for early gastric cancer. A new concept in laparoscopic surgery." Surg Endosc 1995, 9:169-171.

7. Filipi CJ, Perdikis G, Hinder RA, et al.: "An intraluminal surgical approach to the management of gastric bezoars." Surg Endosc 1995, 9:831-833.

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 preperitoneal inguinal hernia repair without peritoneal incision." Surg Endosc 1993, 7:159-162.

11. Cheatle, GL: "An operation for the radical cure of inguinal and femoral hernia." Br Med J 1920, 2:68-69.

12. Henry, AK: "Operation for femoral hernia by a midline extraperitoneal approach." Lancet 1936, 1:531-533.

13. Webb DR, Redgrave N, Chan Y, et al.: "Extraperitoneal laparoscopy: Early experience and evaluation." Aust N Z J Surg 1993, 63:554-557.

14. Himpens J, Van Alphen P, Cadiere GB, et al.: "Balloon dissection in extended retroperitoneoscopy." Surg Laparosc Endosc 1995, 5:193-196.

Description | Table of Contents | List of Contributors

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