The patient’s position depends on the selected surgical procedure. A transperitoneal approach is used for any adrenal or renal dissection. In this approach, the patient is placed in a modified lateral position permitting easy access to the abdominal cavity. In retroperitoneoscopic approach, the patient is in a stiff lateral position. The decision of going for retroperitoneal or transperitoneal approach totally depends on the surgeon. Pelvis procedures such as prostatectomy require a specialized position called as Trendelenburg, where the leg is in an elevated position and head is down.
- Transperitoneal approach: A pneumoperitoneum is established prior to a laparoscopic procedure. Pneumoperitoneum means the presence of gas in the peritoneal cavity. Usually, CO2 is used for insufflation in laparoscopy. Two techniques are used to achieve pneumoperitoneum; open approach, and Verress needle. In Verress technique, the needle is inserted at the cranial perimeter of the umbilicus. Special care needs to be taken in order to avoid any damage to bowels or any major blood vessels. The open approach is implemented to shun away from the possible complications associated with Verress technique. In open approach, a slightly larger incision is made for the surgery. The incision size is of not much importance as the same incision can be used for post placement and/or specimen retrieval.
- Extraperitoneal approach: In extraperitoneal approach, ample space is not available as compared to intraperitoneal approach and therefore space is artificially created. A small incision is made at the 12th rib in the mid-axillary line; then mostly a balloon dilatation is performed for making room for the surgery. The working space is created between the psoas muscle and the posterior layer of Gerota’s fascia. Adequate working space is required for introduction of trocars.
- Port placement: Ports acts as a portal for the placement of other instruments during the surgery. Once the working space is established then only it is safe to place the Ports. Post laparoscope insertion, the surgery space is carefully inspected for any adhesions and abnormalities. Further, additional Ports are introduced under direct vision of the surgeon. Special care is taken while placing the Port in the cavity to avoid any injury to the sutures.
Two things are kept in mind before the surgery, one is excellent visualization, and the other one is the duplication of open surgery principles. Similar to an open surgery, laparoscopic devices are composed of scissors, dissectors, vascular staplers, graspers, scalpels and more. The only difference is that they are simply elongated. Whenever, laparoscopic procedures require specimen retrieval, it is achieved using a specimen retrieval bag. It is inserted through the port and then unfolded in the surgical space. The specimen is entrapped in the bag, and then it is closed for extraction. Once the specimen is extracted, the laparoscope is re-introduced to verify the presence of bleeding. In order to control any sort of unexpected bleeding, the ports are removed under direct vision. The pneumoperitoneum is deflated before the removal of the last trocar. These small incisions are then closed similarly as performed in an open surgery.
Post-operative complications are usually very less in expert hands. Patients should take note of any abnormal sensation post laparoscopic surgery. If bowels are injured thermally or mechanically, then symptoms will generally occur in several days. In case of any bladder lesions caused during the surgery, the patient may develop urinary ascites. Laparoscopic surgery is known for its limited post-operative pain. If pain persists, the patient should consult the doctor as incomplete deflation may cause some pain in the shoulder girdle.