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Core Laparoscopic Skills

Core Laparoscopic Skills

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Core Laparoscopic Skills

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Jan 31, 2018


The development of laparoscopic surgery has vastly changed the shape of surgical practice over the last century, thanks to early 20th Century surgical pioneers. In the 21st Century, laparoscopic surgery is now commonplace within most surgical specialties. It is critical that those performing laparoscopic surgery do so in a safe manner and, therefore, the acquisition of safe laparoscopic skills is essential for surgical trainees.
The Core Laparoscopic Skills course was designed to equip junior trainees with the basics of laparoscopic surgical practice at minimal cost. This book is designed to complement the course and enhance the acquisition of these surgical skills, while also providing a reference for ongoing learning and development.
We hope you enjoy reading this book and wish you the best for your career in laparoscopic surgery.
Jan 31, 2018

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Core Laparoscopic Skills - Rhiannon Harries


Chapter 1

Introduction and Overview

Adam P Williams

The Association of Surgeons in Training (ASiT) is a professional body and registered charity working to promote excellence in surgical training for the benefit of junior doctors and patients alike. With a membership of over 2700 surgical trainees from all 10 surgical specialties, ASiT provides support at both regional and national levels throughout the United Kingdom and Republic of Ireland. Originally founded in 1976, ASiT is independent of the National Health Service (NHS), Surgical Royal Colleges, and specialty associations. Governed by an elected Executive and Council, the Association is run by trainees for trainees.

Laparoscopic surgery has enjoyed a remarkable rise in popularity following the first laparoscopic cholecystectomy, performed by Mouret in 1987. Indeed, there is little in the way of intra-abdominal surgery that cannot be tackled with this minimally invasive technique. It is therefore a critical skill for all general surgical trainees to acquire. ASiT’s Core Laparoscopic Skills course is specifically designed to provide a firm foundation in both the theory and the practical aspects of laparoscopy that we hope you will be able to build on as your training progresses.

In the development of this course, ASiT has aimed to ensure the syllabus is flexible enough to cater for both medical students and foundation doctors, and also that the course is financially viable for all trainees. This book provides an overview of this syllabus and covers:

•The principles of safe laparoscopy.

•Safe set-up and positioning for the patient.

•How to optimise surgical ergonomics.

•Establishing pneumoperitoneum and the potential risks.

•The steps in performing a laparoscopic appendicectomy.

•The steps in performing a laparoscopic cholecystectomy.

•Laparoscopic suturing.

•Energising devices and staplers.

•Safe port site closure.

In surgery, there is no substitute for careful practice. That being said, I hope this book provides you with a strong foundation in laparoscopic skills so that, combined with practice, you are rewarded with excellence in your future career. I wish you every success.

Mr Adam P Williams,

ASiT President, 2016-17.

Chapter 2

Principles of laparoscopy

Elizabeth J Elsey


By the end of the chapter you will be able to:

•Define laparoscopic surgery

•Describe the history of laparoscopic surgery

•Understand the basic components of laparoscopic surgery


Surgical technology is constantly evolving, with new techniques and approaches emerging all the time. Surgeons are now able to perform procedures using a laparoscopic approach that would have been unheard of 20 years ago, making these exciting times in which to be training and working as surgeons. Most importantly, the evolution of surgical technology is improving patient care and experiences, both now and for the future.

What is Laparoscopic Surgery?

When surgery is performed using an open approach, the surgeon incises the skin and underlying structures in order to gain direct access to internal anatomical structures. In contrast, laparoscopy utilises skin incisions, which are usually very much smaller than those of open surgery, to permit the insertion of laparoscopic instruments, with which internal structures can be visualised and indirectly handled. In order to be able to perform laparoscopic surgery, sufficient space must be created internally in order to visualise internal structures and articulate instruments and tissues. This may involve the introduction of a medium to transform a potential space, such as the peritoneal cavity, into an actual space, the pneumoperitoneum, or gas-filled peritoneal cavity. In other anatomical regions, the medium may be fluid, such as in arthroscopy or cystoscopy.

The evolution of laparoscopy

The history of laparoscopic surgery

The technique of introducing a gas into the abdomen to create a pneumoperitoneum and examine the contents of the abdomen was first described by Georg Kelling in 1901¹. Kelling first performed laparoscopy on a dog, using a cystoscope to examine the abdomen. There swiftly followed developments to the technique, equipment and instruments used. In 1937 Janos described the use of his eponymous Veress needle in the abdomen, for insufflation². An open technique for creation of the pneumoperitoneum using a trocar was invented by Hasson and is the favoured technique for many surgeons in modern laparoscopic surgery³. Establishing safe laparoscopic access is discussed in detail in chapter 4 of this book.

The first example of widespread use of laparoscopy as an alternative surgical approach was in gynaecology, in which procedures such as tubal ligation and division of adhesions were increasingly performed laparoscopically in the 1970s and 80s⁴. The first laparoscopic cholecystectomy was performed in Germany, by Erich Mühe in 1985. At this stage, laparoscopic technology had not developed sufficiently to transmit pictures to a monitor screen in the way we understand laparoscopic surgery today. Instead, visualisation was achieved by directly looking into the laparoscope⁵. Mühe continued to practice the technique and just 2 years later had performed 97 laparoscopic cholecystectomies⁶. Philippe Mouret of France was widely misrepresented as having performed the first laparoscopic cholecystectomy, and Mühe’s contribution to the technique was only recognised over a decade later, in 1999, by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES)⁷.

Development of routine use

Laparoscopic cholecystectomy steadily became more widely used across the latter part of the twentieth century and uptake increased significantly with the advent of technology to transmit images from the laparoscope to a separate television monitor⁵. By 1992, just 7 years after the first procedure was performed in humans, over 80% of cholecystectomies in the USA were being performed laparoscopically⁵.

As well as the increasing use of these pioneering laparoscopic procedures, the portfolio of procedures possible to perform using a laparoscopic approach also rapidly increased, more and more procedures being attempted laparoscopically. Appendicectomy, inguinal hernia repair, hiatus hernia repair and gastric fundoplication, adrenalectomy and splenectomy were all among the earlier procedures to be performed laparoscopically⁶. Laparoscopy is now recognised as an integral component of surgical practice, and understanding of the principles, techniques and technical skills are commonplace in surgical curricula across surgical specialties. The use of laparoscopic surgery has progressed enormously, with increasingly complex procedures performed via this approach.

Evolving technology

As surgical boundaries have been pushed, and increasingly demanding procedures have been performed laparoscopically, technological innovations have allowed laparoscopic surgery to progress into the twenty-first century. Some procedures have benefited from the use of a hand-port with a sealable gel top, allowing the surgeon to insert a single hand into the abdomen for retraction of internal tissues. This port can also be used to extract the specimen being excised in the case of resectional procedures⁸.

Natural orifice transluminal endoscopic surgery (NOTES) was described in 2004⁹, and uses a combination of endoscopic and laparoscopic techniques to offer the supposed benefit of ‘scar-free’ surgery. It has failed to develop significantly as a widely-accepted technique and remains the subject of some controversy¹⁰.

Single incision laparoscopic surgery (SILS) is another area of innovation in laparoscopic surgery. This technique uses specially designed ports, which permit access of several laparoscopic instruments, including the camera, via a single port site. Specially designed articulating instruments enable the surgeon to triangulate in order perform the operation without significant instrument clash¹¹.

Laparoscopic Equipment

Laparoscopic surgery requires a range of components, commonly described as the laparoscopic stack. The key components of this comprise a gas (or fluid) delivery system, a lightbox, a camera and a monitor. For the purposes of this book we describe the stack used commonly for intra-abdominal surgery.

Gas delivery system

The gas delivery system is required to create and maintain the operating space (typically the pneumoperitoneum). The gas delivery system constitutes a cylinder, containing the gas of choice (most commonly CO2); insufflator, which regulates the pressure of the gas; tubing; filter; and laparoscopic port. The insufflator displays the flow rate of the gas and a pre-set maximum gas pressure, and allows the operating surgeon to determine the flow rate of gas. Some insufflators have features to warm and humidify the gas being used.


The lightbox is simply, but importantly, the light source for the surgery. Light is transmitted from the source to the laparoscope using a light cable, typically made of fibre-optic bundles. Care must be taken to not leave a light lead unconnected to the laparoscope on the surgical drapes or in

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