Minimally invasive laparotomies

September 2006 

.

The concept that the quality of patient recovery from surgical procedures is directly related to the degree of procedure invasiveness is widely understood in medical practice. The longer and more complex the surgery, the more likely that patient recovery time will be longer. Conversely, the less complex and invasive a procedure is, the quicker a patient may recover, return home, and resume routine daily activity.

Laparotomy procedures are no exception. The length of the laparotomy incision, quality of visualization, time requirements for exploring, extent of the dissection, diagnosing and treating abdominal conditions, and the available tools with which to manipulate organs and tissues all contribute to the degree of laparotomy invasiveness and affect patient recovery.

The advent of laparoscopy is a byproduct of the quest to reduce trauma to the patient. In certain procedures, laparoscopy holds distinct advantages over laparotomy, including decreased morbidity and mortality, reduced blood loss, less need for postoperative analgesia, and shorter hospital stays. However, in other procedures, laparoscopy cannot provide the necessary extent of visualization or safety required for proper exploration and diagnosis. 

Consequently, laparotomies continue to be widely utilized when greater access is needed to safely complete surgical procedures. The question remains, though, ‘How, then, do we minimize its invasiveness?’ Here are three suggestions:

1.  Know which procedures are best treated with laparotomy vs. laparoscopy

Which procedure should be used to treat:

• Ovarian cystectomies

• Inflammation of the pancreas, appendix, or intestinal pockets

• Post-partum tubal ligation

• Hysterectomies

• Ectopic pregnancies

• Infertility investigation

• Tubal reanastamosis

• Staging procedures for cancer of the ovary, colon, pancreas or liver

• Blunt or penetrating trauma to the abdomen

The answer is: It depends. These clinical procedures, among others, are all performed using both laparotomy and laparoscopy. The key is knowing that laparotomies are preferred when the surgeon:

a.   Anticipates limited exposure or visualization of basic structures due to a large mass obstructing view

b.   Determines that insertion of a needle or a trochar into the abdomen might be prevented by large masses

c.  Suspects massive adhesions or a certain cancer staging procedure

2.  Reduce your incision size with mini-laparotomies

Mini-laparotomy, generally referred to as “minilap,” is an abdominal surgical approach by means of an incision less than 5 cm in length. As a sterilization procedure for permanently occluding the fallopian tubes, mini-laps have been performed safely and frequently in a wide range of countries for more than 30 years.

 Major morbidity appears to be a rare outcome for both laparoscopy and mini-laparotomy. It is important to note that laparoscopy carries a greater risk than mini-laparotomy of major morbidity (such as bowel or vascular injury) that may be life-threatening or may require additional surgery^[1].

Mini-laparotomy also has several advantages over laparoscopy^[2] :

• Mini-laparotomy can be offered more widely than laparoscopy because it can be performed by a broader range of providers

• Mini-laparotomy can be used for postpartum sterilization

• Mini-laparotomy requires simple, inexpensive, and easily maintained surgical equipment

• Mini-laparotomy involves low start-up and continuing costs

• Mini-laparotomy can be offered at a variety of sites, since it does not require high-level facilities

3.  Utilize minimally invasive laparotomy instruments

Because of the sensitivity of abdominal organs and tissues, grasping, retracting and manipulating abdominal tissue should be done with utmost care. The delicate nature of the abdominal organs contributes to a high risk of infection if organs rupture or are perforated.

 Typically, tissue forceps, retractors, clamps and linear traumatic graspers (both sharp-tipped and blunt-tipped) are used during laparotomies to gain visualization and manipulate tissues and organs when necessary. Because of their design and high pressure forces on small areas of tissue, extreme caution should be exercised anytime these devices are used. 

Laparotomies are an essential part of surgical practice today. Certain factors contribute directly to the degree of invasiveness of this procedure. However, with sound procedural decisions, exploration of mini-laparotomies, and utilization of new technology, patients can experience shorter recovery times and hospital stays.

^[1]  Kulier et al., 2003;WHO, 1982

^[2]  Glasser, Mark H. Minilaparotomy: A Minimially Invasive Alternative for Major Gynecologic Abdominal Surgery. The Permanente Journal, Winter 2005, Volume 9, No. 1.