Atlas of •

Laparoscopic Surgery

Theodore N. Pappas Pro/es 0 1' 0/ 11 rgel] Chief, urg ical eJVices

urbam VA Medical enler Duke · niver ilJ Mee/ical enler Duke niver i(y MedicClI chool Durham. orlh CCiroliJ1C1

Lewis B. Schwartz A s i tanl Professor Department 0/ /Irgel)' Pritzker cboolofMedicille

niver ilJ of Cbicago Cbicago lilinois

Steve Eubanks A iSlam Profe sor of l/ rgel]' Direclor if urgical Endoscop) Duke nivel ilJ' illedicClI enler Duke niversifJ' Ifee/ical cbool Durham. Vorlh Carolil1Cl

With 36 contributors

Springer-Science+ßusiness Media, LLC

Atlas of

Laparoscopic Surgery

CURRENT MEDICINE 400 MARKET STREET

SUITE 700 PHILADELPHIA, PA 19106

MANAGING EDITOR:

DEVELOPMENT EDITOR:

ART DIRECTOR:

DESIGN AND LAyOUT:

ILLUSTRATION DIRECTOR:

Lori Bainbridge Elise M. Paxson Paul Fennessy Robert LeBrnn and Lisa Caro Ann Saydlowski

ILLUSTRATORS: Christopher Burke, Rob Gordon, Claudia Grosz, Nancy Kaplan,

INDEXER:

Tanya Leonello, Sarah McQueen, fames Perkins, and Susan Tanner AnnBlum

PRODUCTION:

TYPESETTING DIRECTOR:

David Myers and Lori Holland Colleen Ward

Atlas of laparoscopic surgery / [edited by] Theodore N. Pappas, Lewis B. Schwartz, Steve Eubanks; with 36 contributors.

p. cm. Includes bibliographical references and index.

1. Endoscopic surgery--Atlases. I. Pappas, Theodore N., 1955- . 11. Schwartz, Lewis B., 1960- . III. Eubanks, Steve, 1959- .

[DNLM: 1. Surgery, Laparoscopic--methods--atlases. WO 517 A8798 1996] RD33.53.A86 1996 617' .05--dc20 DNLM/DLC for Library of Congress 95-41439

CIP

ISBN 978-1-4757-9318-5 ISBN 978-1-4757-9316-1 (eBook) DOI 10.1007/978-1-4757-9316-1

54321

Copyright 1996 by Springer Science+Business Media New York Originally published by Current Medicine in 1966. Softcover reprint ofthe hardcover 1st edition 1966 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of the publisher.

Fo~e\No~d The field of laparoscopic surgery has progressed at an astonishing pace, and new techniques are continuously being devised. The impetus for the widespread applica­tion of this method was initiated by Mouret in 1987 in his performance of cholecystectomy by the laparoscopic approach. The great majority of gallbladders are now being removed by laparoscopic cholecystectomy with quite favorable results.

It is generally agreed that the laparoscopic approach for many surgical procedures is less invasive, produces less trauma to tissues and organs, is associated with less post­operative discomfort, and is accompanied by a more rapid return of the patient to normal. Moreover, while the instrumentation and equipment used in laparoscopic procedures are often individualized and more expensive, recent studies have shown that this approach can be cost­effective in comparison with standard open surgical proce­dures, and especially with the short hospital stay.

The authors of this text have primarily drawn from their experiences in laparoscopic surgery at the Duke-US Surgical Endosurgical Center at the Duke University Medical Center. This is the site of considerable develop­mental research on innovative instrumentation and studies to devise and assess new procedures. The center is fully equipped with the la test technology available. In addition there is a vivarium that has an experimental surgical unit and facilities for long-term postoperative care . In this

setting, a number of new procedures have been devised and evaluated. The center also has an excellent surveil­lance plan for outcome studies of patients undergoing laparoscopic procedures. This combination of facilities and services has led to significant advances as weIl as a thorough follow-up of a number of clinical series. .

The Atlas 0/ Laparoscopic Surgery is composed of 28 chapters with authoritative commentaries and illustrations of a number of surgical procedures amenable to laparo­scopic techniques. The chapters are effectively planned, with a thorough discussion of the procedure with the appropriate anatomical, pathophysiological, and differential diagnostic features. The surgical techniques are graphically depicted by a combination of intra operative illustrations and selected photographs. The legends accompanying each of the illustrations provide an unusually clear description of each step during the procedure in what is essentially a fail­safe approach. A selected bibliography follows each chapter with the most pertinent citations from the literature.

Occasionally a new text appears which makes such a convincing impression that a prediction can be made with confidence. This Atlas 0/ Laparoscopic Surgery is a perfect example, as it is composed of a host of procedures that can be effectively achieved by laparoscopy. It is a masterwork by talented contributors and is a must for all those involved in the field.

David C. Sabiston, Ir, MD

v

PI""eface The Atlas of Laparoscopic Surgery represents the cumula­tive thoughts of a group of surgeons, predominantly from Duke University Medical Center, in the early 1990s. Our hope is to capture some of the nuances of laparoscopic surgery that we experienced early in the development of advanced laparoscopy. The Editors fully realize that the information presented will undergo changes over the next several years as the field of advanced laparoscopy matures.

We have chosen the word "laparoscopie" in the title of this book as a generic term to include both laparoscopy and thoracoscopy. The text will probably be most benefi­dal for the minimally invasive general surgeon who occa­sionally does thoracoscopie work. The authors have made an effort to include alternative techniques to the ones that are frequently used at Duke. The Editors acknowledge that there are many ways to successfully complete most operations, and where a single technique is presented, many other techniques could be substituted. We find that the techniques described are effective and usually quite safe. Efforts have been made to include techniques that are widely applicable for most advanced laparoscopic surgeons, and given the choiee between complex versus simple techniques, we tend to use the least complex and shortest operation. Many of the operations, such as the laparoscopic antireflux procedures and laparoscopic gastrostomy and jejunostomy, are spedfically detailed to reduce the learning curve for these procedures as much as possible. Although laparoscopic cholecystojejunostomy

VI

does not have broad application, the technique as it is described in this chapter has proven successful in our experience. The fields of laparoscopie appendectomy and laparoscopic herniorrhaphy continue to be quite con­tentious, but the techniques presented in these chapters should be helpful if the readers choose to include these operations in their surgical repertoire. The chapter on pediatrie endosurgery is meant mostly as an overview, and the Editors recognize that entire texts have been devoted to this subject.

The Editors would like to thank Dr. David C. Sabiston, Jr, for his foreword and for his great support in the devel­opment of endosurgery at Duke University Medieal Center. Dr. William C. Meyers is a contributor to this atlas and is also the driving academie force behind most of our endo­surgical innovations. Finally, the Editors would like to thank Leon Hirsch and the US Surgical Corporation for their philanthropie support of the Department of Surgery at Duke Hospital in our efforts to advance the surgical knowledge of endosurgery.

Our sincere hope is that this atlas will simplify and orga­nize surgieal thought for the advanced laparoscopist. The operations described should be safe, should not require extensive operating time, and should be effective for the diseases described.

Tbeodore N. Pappas Lewis B. Schwartz

Steve Eubanks

Hartmuth B. Bittner, MD, PhD Senior Assistant Resident Department of Surgery Duke University Medical Center Durham, North Carolina

Gene D. Branum, MD Assistant Professor Department of Surgery Emory University School of Medicine Emory University Hospital and VA Medical Center Atlanta, Georgia

Ravi S. Chari, MD Chief Resident Department of Surgery Duke University Medical Center Duke University Medical School Durham, North Carolina

Christine A. Cheng, MD Resident in Plastic and Reconstructive Surgery University of Utah Medical Center Salt Lake City, Utah

Bryan M. Clary, MD Senior Assistant Resident Duke University Medical Center Durham, North Caro/ina

Bradley H. Collins, MD Senior Assistant Resident Department of Surgery Duke University Medical Center Durham, North Carolina

Thomas A. D'Amico, MD Fellow in Cardiothoracic Surgery Department of Cardiothoracic Surgery Duke University Medical Center Durham, North Carolina

Andrew M. Davidoff, MD Fellow Department of Surgery University of Pennsylvania Children 's Hospital of Philadelphia Philadelphia, Pennsylvania

James M. Douglas,Jr, MD Director of Cardiovascular Surgery St. joseph Hospital Bellingham, Washington

Steve Eubanks, MD Assistant Professor of Surgery Director of Surgical Endoscopy Duke University Medical Center Duke University Medical School Durham, North Carolina

John P. Grant, MD Professor Department of Surgery Duke University Medical Center Duke University Medical School Durham, North Carolina

David H. Harpole, Jr, MD Assistant Professor Division of 1boracic Surgery Haroard Medical School Boston, Massachusetts

Scott H. Johnson, MD Assistant Professor of Surgery Division of Cardiothoracic Surgery Washington University School of Medicine Christian Northeast Hospital St. Louis, Missouri

Kevin P. Landolfo, MD Assistant Professor of Surgery Department of Surgery Duke University Medical Center Durham, North Carolina

Henry L Laws, MD Director of Surgical Education Carraway Methodist Medical Center Clinical Professor of Surgery University of Alabama School of Medicine Birmingham, Alabama

H. K.im. Lyerly, BS, MD Associate Professor, General and 1boracic Surgery Assistant Professor of Pathology Assistant Professor of Immunology Duke University Medical Center Duke University Medical School Durham, North Carolina

Samuel M. Mahaffey, MD Assistant Professor Department of Surgery Duke University Medical Center Duke University Medical School Durham, North Carolina

James R. Mault, MD Fellow in Cardiothoracic Surgery Department of Surgery Duke University Medical Center Durham, North Carolina

Cary H. Meyers, MD Chief Resident in Surgery Department of Surgery Duke University Medical Center Durham, North Carolina

vii

WUliam C. Meyers, MD Professor of Surgery Department of Surgery Duke University Medical Center Duke University Medical School Durham, North Caro/ina

SeanJ. Mulvihill, MD Associate Professor Department of Surgery University of Calijornia, San Francisco,

School of Medicine San Francisco, Calijornia

Lucian Newman m, MD Gadsden RegionallRiveroiew Regional Gadsden, Alabama

Keith T. Oldham, MD Professor Department of Surgery and Pediatrics Duke University Medical School Duke University Medical Center Durham, North Carolina

Theodore N. Pappas, MD Professor of Surgery Chief, Surgical Seroices Durham VA Medical Center Duke University Medical Center Duke University Medical School Durham, North Caro/ina

Marco G. Patti, MD Assistant Professor Department of Surgery University of Calijornia, San Francisco,

School of Medicine San Francisco, Calijornia

Jeffrey C. Pence, MD Chief Resident General and 1boracic Surgery Duke University Medical Center Durham, North Caro/ina

WUliam N. Peugh, MD, D.PhU C/inical Assistant Professor of Surgery University of Nevada Las Vegas, Nevada

David T. Prlce, BS, MD Resident in Urology Division of Urology Department of Surgery Duke University Medical Center Durham, North Caro/ina

viii

R. Lawrence Reed n, MD Associate Professor of Surgery and Anesthesiology Department of Surgery Duke University Medical Center Duke University Medical School Durham, North Caro/ina

Cary N. Robertson, MD Associate Professor Division of Urology Department of Surgery Duke University Medical Center Durham, North Carolina

David C. Sabiston, Jr, MD fames B. Duke Professor of Surgery and Chief of StaJf Duke University Medical Center Duke University Medical School Durham, North Carolina

Lewis B. Schwartz, MD Assistant Professor Department of Surgery Pritzker School of Medicine University of Chicago Chicago, I//inois

Phillip P. Shadduck, MD Consultant Department of Surgery Duke University Medical Center Attending Surgeon Durham Regional Hospital Attending Surgeon Durham Veterans Administration Hospital Durham, North Caro/ina

John T. Soper, MD Professor Department of Obstetrics and Gynecology Duke University Medical Center Duke University Medical School Durham, North Caro/ina

James D. St. Louis, MD Senior Assistant Resident Department of Surgery Duke University Medical Center Duke University Medical School Durham, North Caro/ina

Christopher R. Watters, MD Executive Surgical Center, Inc. Raleigh, North Caro/ina

Co~te~ts 1. Lapa .... oscopic JV\st .... I.,u't\eV\tatioV\ aV\d Basic TechV\iqi.l\es

Thomas A. D'Amico Lewts B. Scbwartz Steve Eubanks

The Operating Room .. ... ................................................... 1.2 Imaging Systems ............................................. .. ............. 1.2 Laparoscopes ......................... . ................................... 1.2 Light Source ............................. .. ........... .. .... . . . ....... . ... 1.2 Video Camera .. . .... . .... . .. .. .. ... ..... . ........... . .... ...... ........ ... 1.3 Video Monitors ............................... ...................... ........ 1.3 Three Dimensional and High Definition Television .. .. ......... .... ................. 1.3 Equipment . ............................. . .......... .. ... ................ . 1.3 Instruments ....................................... ... .... . ............ .... 1.6 Training and Credentialling . ........ . . .. ............. . ... . ............. .. . .... 1.8

2. Lapa .... oscopic AV\ti .... eBi.I\x P .... ocedi.l\ .... es Hartmutb B. Btttner Theodore N. Pappas

Anatomy ........... . .............................................. . ...... 2.2 Pathophysiology, Presentation, and Differential Diagnosis ........ .. ........ .. ........ . 2.5 Surgical Technique .............. . ................. . .............. . .... . ... 2.10 Results .. ... .................. . ........... .. ......... .... .... ... .... .. .. 2.15

3. Lapa .... oscopic Vagotomy Cbrlsttne A. Cbeng Theodore N. Pappas

Anatomy . . ............ . .. .. ....... . ...... . ............................... 3.3 Pathophysiology, Presentation, and Differential Diagnosis .................... . ........ 3.4 Surgical Technique ..................................... .. . ................. 3.6 Results .............. . ................ ..... ........ . .................... 3.14

4. Lapa .... oscopic aast .... ostomy aV\d 3eji.l\V\ostomy Ca", H. Meyers Jobn P. Grant

Anatomy .. ........ . ........ . ................... . ....... ... .... .. ......... 4.3 Surgical Technique ......... .. . .... ............ .. ..... .... .... .... .... ... ... 4.4 Results . . .... ............... . ........................................... 4.13

5. Lapa .... oscopic aast .... ojeji.l\V\ostomy Bradley H. ColUns Theodore N. Pappas

Anatomy ..................... .. ......... . .................... . .......... . 5.3 Pathophysiology, Presentation, and Differential Diagnosis .............. . .............. 5.4 Surgical Technique ............ ...... ....................................... 5.8 Postoperative Management ................... .. .................. ... ..... . .. . 5.13 Results ................................................................. 5.13 Conclusions .............................................................. 5.13

ix

x

6. Basic Tech~iques of Lapal"oscopic CholecystectoW\y Cbrlstopber R. Watters

Anatomy ................................................................ 6.2 Pathophysiology, Presentation, and Differential Diagnosis ............................ 6.2 Surgical Technique ........................................................ 6.3 Results ................................................................. 6.7

7. Lapal"oscopic Chola~9io91"aphy Bryan M. Clary Tbeodore N. Pappas

Anatomy ................................................................ 7.3 Pathophysiology, Presentation, and Differential Diagnosis ............................ 7.5 Diagnosis and Indications far Intraoperative Cholangiography ........................ 7.5 Surgical Technique ........................................................ 7.7 Alternative Technique ..................................................... 7.11 Results ................................................................ 7.15

8. Lapal"oscopic Ma~ageW\e~t of Choledocholithiasis Lewis B. Scbwartz Tbeodore N. Pappas

Anatomy and Pathophysiology ............................................... 8.2 Clinical Presentation ....................................................... 8.3 Management of Choledocholithiasis ............................................ 8.3 Surgical Technique ........................................................ 8.4 Results ................................................................. 8.7

9. CoW\plicatio~s of Lapal"oscopic CholecystectoW\y Gene D. Branum Tbeodore N. Pappas

Anatomy ................................................................ 9.2 Biliary Complications ...................................................... 9.2 Diagnosis ............................................................... 9.6 Treatment ............................................................... 9.7 Prevention of Injuries ...................................................... 9.8 Miscellaneous Complications ................................................. 9.9 Results ................................................................ 9.11

10. Lapal"oscopic Cholecystojeju~ostoW\y Ravi s. Cbarl Tbeodore N. Pappas

Anatomy ............................................................... 10.2 Pathophysiology, Presentation, and Differential Diagnosis ........................... 10.3 Surgical Technique ....................................................... 10.4 Alternative Technique ..................................................... 10.8

11. Lapal"oscopic Livel" Biopsy Ravi S. Cbarl WilUam C Meyers

Anatomy ............................................................... 11.2 Pathophysiology, Presentation, and Differential Diagnosis ........................... 11.4 Surgical Technique ....................................................... 11.6 Complications ........................................................... 11.8

12. Lapa,,-oscopic Sple~ectomy ]e.ffrey C Pence KeUb T. Oldbam

Anatomy ............................................................... 12.2 Pathophysiology, Presentation, and Differential Diagnosis ........................... 12.4 Surgical Technique ....................................................... 12.5 Results ................................................................ 12.7

13. Lapa,,-oscopic Meckel 's Dive .. ticlAlectomy Lewis B. Scbwartz Tbeodore N. Pappas

Anatomy and Embryology .................................................. 13.2 Pathophysiology ......................................................... 13.3 Surgical Technique ....................................................... 13.5 Results ................................................................ 13.7

14. Lapa..-oscopic Small Bowel Resectio~ a~d Adhesiolysis WilUam N. Peugb Steve Eubanks

Anatomy ............................................................... 14.2 Pathophysiology, Presentation, and Differential Diagnosis ........................... 14.2 Surgical Technique ....................................................... 14.3

15. Lapa..-oscopic Repai..- of Diaph..-agmatic t-Ie..-~ia Luctan Newman JII Steve Eubanks

Embryology and Anatomy .................................................. 15.2 Pathophysiology, Presentation, and Differential Diagnosis ........................... 15.2 Surgical Technique ....................................................... 15.4

16. Lapa..-oscopic Appe~dectomy Lewis B. Scbwartz Tbeodore N. Pappas

Anatomy ............................................................... 16.2 Pathophysiology, Presentation, and Differential Diagnosis ........................... 16.3 Surgical Technique ....................................................... 16.6 Results ............................................................... 16.12

17. Lapa..-oscopic t.~te..-ic Dive..-sio~ ]ames R. Mault H. Kim Lyerly

Surgical Technique ....................................................... 17.3 Results ................................................................ 17.6

18. Lapa..-oscopic-assisted Colectomy a~d Abdomi~ope..-i~eal ResecJio~

Gene D. Branum Tbeodore N. Pappas

Anatomy ............................................................... 18.2 Surgical Technique ....................................................... 18.3 Discussion ............................................................. 18.10

xi

xii

19. Lapa~oscopic Jt\guit\al t-Ie~t\io~~haphy PbUUp P. Sbadduck Lewis B. Scbwartz Steve Eubanks

Anatomy ............................................................... 19.3 Pathophysiology, Presentation, and Differential Diagnosis ........................... 19.4 Surgical Technique ....................................................... 19.4 Results ............................................................... 19.13

20. Lapa~oscopic 6valuatiot\ it\ Abdomit\al T~auma James D. st. Louis R. Lawrence Reed 1I

Background ............................................................ 20.2 Surgical Technique ....................................................... 20.3

21. Pediat~ic 6t\dosu~ge~y Andrew M. Davtdoff KeUb T. Oldbam Samuel M. Mabaffey

Special Considerations ..................................................... 21.2 Endosurgical Procedures ................................................... 21.3 Conclusions ............................................................ 21.11

22. Lapa~oscopic-assisted Vagit\al t-Iyste~ectomy With o~ Without Removal of the Adt\exae

Jobn T. Soper

Anatomy ............................................................... 22.2 Indications ............................................................. 22.3 Surgical Technique ....................................................... 22.4 Results ............................................................... 22.10

23. Lapa~oscopic Stagit\g Pelvic Lymphadet\ectomy fo~ P~ostate Cat\ce~

David T. Prlce Ca", N. Robertson

Anatomy ............................................................... 23.2 Pathophysiology, Presentation, and Differential Diagnosis ........................... 23.2 Surgical Technique ....................................................... 23.4 Results ............................................................... 23.10

24. Diagt\ostic Tho~acoscopy Scott H. Jobnson James M. Dougl4s,Jr

Anatomy ............................................................... 24.2 Indications for Diagnostic Thoracoscopy ....................................... 24.3 Surgical Technique ....................................................... 24.6 Results ............................................................... 24.11

25. Tho~acoscopic Pe~ica~diectomy Scott H.Jobnson James M. Douglas,Jr

AIlatomy ............................................................... 25.2 Pathophysiology ......................................................... 25.2 Presentation and Differential Diagnosis ........................................ 25.3 Surgical Indications ....................................................... 25.3 Surgical Technique ....................................................... 25.4 Results ................................................................ 25.6

26. Tho~acoscopic PlAlmo~a~y Resectio~ James R. Mault DavidH. Harpole,Jr James M. Douglas,Jr

Management of a SoHtary Pulmonary Nodule .................................... 26.2 Anatomy ............................................................... 26.3 Surgical Technique ....................................................... 26.5 Results ............................................................... 26.10

27. Tho~acoscopic Spla~ch~icectomy Kevin P. Landolfo HenryL Laws WiUiam C Meyers

Anatomy ............................................................... 27.2 Surgical Technique ....................................................... 27.4 Results ................................................................ 27.7

28. t-Ie"e~ Myotomy fo~ t.sophageal Achalasia Marco G. Patti SeanJ. MulvibiU

Anatomy ............................................................... 28.2 Physiology ............................................................. 28.2 Pathophysiology of Achalasia ................................................ 28.2 CHnical Findings ......................................................... 28.3 Surgical Technique ....................................................... 28.5 Laparoseopie Heller Myotomy ............................................... 28.8 Results ................................................................ 28.8

Jndex ............................................................... 1.1

xiii