Laparoscopy technique

Helmreich-Becker, I., Meyer zum Buschenfelde, K.-H., Lohse, A.W. Safety and feasibility of a new minimally invasive diagnostic laparoscopy technique. Endoscopy 1998 30 756-762... 

Understaging of ovarian cancer remains a common problem (20%-40%) in clinical routine. It occurs frequently, when the initial surgery had been performed under the presumption of a benign process, due to laparoscopy technique, and lack of oncologic specialist expertise [4]. 

Laparoscopy is a low-risk instrumental examination technique for the abdominal cavity with a high degree of diagnostic relevance and low personnel input. 

Each laparoscopy should aim at a visual assessment of the spleen in terms of (7.) size, (2.) colour, (i.) shape, and (4.) identifiable spleen diseases. Special mention should be made of capsular fibrosis, hyalinosis ( sugar-coated spleen ), tumours (e. g. Hodgkin s disease, retothelial sarcoma), tuberculosis, splenic cysts, splenic infarction (s. fig. 35.10) and splenic haematoma. Given appropriate positioning, the spleen is visible in 80% of cases. In the case of myeloproliferative diseases, a biopsy of the spleen (e. g. by means of the Menghini technique) can provide a definitive diagnosis, (s. pp 135,253) (s. figs. 11.1 14.7) (see chapter 11)... 

After carrying out the imaging techniques (if necessary with contrast media) (see chapters 6, 8, 9) and laparoscopy/biopsy (see chapter 7), the strategy of establishing a diagnosis by flow diagram may be recommended in suspected liver tumour , (s. fig. 9.4)... 

The indications for sonography- or CT-guided flne-needle biopsy (FNB) are (i.) contraindications to the use of laparoscopy (s. p. 149) or (2.) if it seems unlikely that previously unresolved findings will be clarified by laparoscopy. In consideration of all relevant findings from sonography or CT as well as the patient s condition, it may be necessary in individual cases to resort to FNB as the primary approach instead of biopsy or laparoscopy, (s. fig. 9.4) The non-availability of laparoscopy or insufficient experience with this technique are in themselves not an indication for percutaneous fine-needle biopsy, (s. fig. 9.4)... 

Direct splenoportography is the most informative procedure for visualizing the portal vein system and its collaterals, (s. p. 181) Yet this technique is costly, time-consuming and high-risk. The injection of contrast medium into the spleen is carried out either percu-taneously (sonography-gmded) or, preferably, by laparoscopy. It is also possible to measure the pressure in the portal vein system. In addition, this method ensures access to the collaterals if radiological obliteration is planned, (s. p. 181)... 

Both the risks and the possibility of obtaining uncertain results are far greater with percutaneous biopsy than with laparoscopically directed biopsy. The latter produces a detailed diagnosis in 97-100% of cases, a result also confirmed by our own observations. (46, 90, 123, 129) Insufficient training in laparoscopy or the non-availability of this examination technique do not constitute an indication for percutaneous biopsy in liver cirrhosis, at least for initial diagnosis, (s. figs. 7.8, 7.15 16.5 28.13 35.2-35.4) (s. pp 160, 161, 408)... 

After discussing the clinical and imaging findings as well as the result of exploratory laparoscopy, it is important to decide on the most promising management in the interdisciplinary conference. Once resection techniques and liver transplantation have been ruled out, the next alternative are interventional procedures (s. tab. 37.9). 

Laparoscopy Laparoscopy should be used to confirm the diagnosis morphologically. This technique provides photodocumentary findings and also affords the possibility of targeted thick-needle, fine-needle or forceps biopsy. Tumour biopsy is only deemed necessary prior to palliative therapy. Moreover, explorative laparoscopy offers a much better overview of the whole abdominal area than does explorative laparotomy - and the risk involved is considerably lower. Carrying out laparotomy staging prior to liver transplantation is, in our opinion, also far less efficient and thus not indicated instead, laparoscopy should be the technique of choice, (s. pp 150, 155, 161, 781)... 

A nnmber of drainage techniqnes have been described nsing endoscopy and laparoscopy. These minimal-access techniques may offer advantages when compared with traditional surgery but probably wiU be used less often than radiologically assisted percutaneous drainage techniques. 

At present, cryoablation is primarily guided by ultrasound and requires an open surgical technique with fewer than 10% of patients treated laparoscopi-cally. Patients are followed-up with CT performed immediately before discharge, at 6 and 12 months after ablation, and annually thereafter. The thermal injury caused by cryoablation appears on CT images as an avascular low-attenuation lesion that slowly decreases in size over time. Reported long-term survival rates for this procedure are 90% for 1 year, 40% for 3 years, and 20% for 5 years (Dodd et al. 2000). 

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