Table Of ContentAtlas o f
•
Laparoscopic
Surgery
Atlas of
Laparoscopic
Surgery
Theodore N. Pappas
Pro/es 0/ rgel]
01' 11
Chief, urgical eJVices
urbam VA Medical enler
Duke · niver ilJ Mee/ical enler
Duke niver i(y MedicClI chool
Durham. orlh CCiroliJ1C1
Lewis B. Schwartz
A si tanl Professor
Department 0/ /Irgel)'
Pritzker cboolofMedicille
niver ilJ of Cbicago
Cbicago lilinois
Steve Eubanks
A iSlam Profe sor of rgel]'
l/
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
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MANAGING EDITOR: Lori Bainbridge
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INDEXER: AnnBlum
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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 setting, a number of new procedures have been devised
astonishing pace, and new techniques are continuously and evaluated. The center also has an excellent surveil
being devised. The impetus for the widespread applica lance plan for outcome studies of patients undergoing
tion of this method was initiated by Mouret in 1987 in his laparoscopic procedures. This combination of facilities
performance of cholecystectomy by the laparoscopic and services has led to significant advances as weIl as a
approach. The great majority of gallbladders are now thorough follow-up of a number of clinical series. .
being removed by laparoscopic cholecystectomy with The Atlas 0/ Laparoscopic Surgery is composed of 28
quite favorable results. chapters with authoritative commentaries and illustrations
It is generally agreed that the laparoscopic approach for of a number of surgical procedures amenable to laparo
many surgical procedures is less invasive, produces less scopic techniques. The chapters are effectively planned,
trauma to tissues and organs, is associated with less post with a thorough discussion of the procedure with the
operative discomfort, and is accompanied by a more rapid appropriate anatomical, pathophysiological, and differential
return of the patient to normal. Moreover, while the diagnostic features. The surgical techniques are graphically
instrumentation and equipment used in laparoscopic depicted by a combination of intra operative illustrations
procedures are often individualized and more expensive, and selected photographs. The legends accompanying each
recent studies have shown that this approach can be cost of the illustrations provide an unusually clear description of
effective in comparison with standard open surgical proce each step during the procedure in what is essentially a fail
dures, and especially with the short hospital stay. safe approach. A selected bibliography follows each
The authors of this text have primarily drawn from their chapter with the most pertinent citations from the literature.
experiences in laparoscopic surgery at the Duke-US Occasionally a new text appears which makes such a
Surgical Endosurgical Center at the Duke University convincing impression that a prediction can be made with
Medical Center. This is the site of considerable develop confidence. This Atlas 0/ Laparoscopic Surgery is a perfect
mental research on innovative instrumentation and studies example, as it is composed of a host of procedures that can
to devise and assess new procedures. The center is fully be effectively achieved by laparoscopy. It is a masterwork
equipped with the la test technology available. In addition by talented contributors and is a must for all those involved
there is a vivarium that has an experimental surgical unit in the field.
and facilities for long-term postoperative care. In this
David C. Sabiston, Ir, MD
v
PI""eface
The Atlas of Laparoscopic Surgery represents the cumula does not have broad application, the technique as it is
tive thoughts of a group of surgeons, predominantly from described in this chapter has proven successful in our
Duke University Medical Center, in the early 1990s. Our hope experience. The fields of laparoscopie appendectomy and
is to capture some of the nuances of laparoscopic surgery laparoscopic herniorrhaphy continue to be quite con
that we experienced early in the development of advanced tentious, but the techniques presented in these chapters
laparoscopy. The Editors fully realize that the information should be helpful if the readers choose to include these
presented will undergo changes over the next several years operations in their surgical repertoire. The chapter on
as the field of advanced laparoscopy matures. pediatrie endosurgery is meant mostly as an overview, and
We have chosen the word "laparoscopie" in the title of the Editors recognize that entire texts have been devoted
this book as a generic term to include both laparoscopy to this subject.
and thoracoscopy. The text will probably be most benefi The Editors would like to thank Dr. David C. Sabiston,
dal for the minimally invasive general surgeon who occa Jr, for his foreword and for his great support in the devel
sionally does thoracoscopie work. The authors have made opment of endosurgery at Duke University Medieal Center.
an effort to include alternative techniques to the ones that Dr. William C. Meyers is a contributor to this atlas and is
are frequently used at Duke. The Editors acknowledge also the driving academie force behind most of our endo
that there are many ways to successfully complete most surgical innovations. Finally, the Editors would like to
operations, and where a single technique is presented, thank Leon Hirsch and the US Surgical Corporation for
many other techniques could be substituted. We find that their philanthropie support of the Department of Surgery
the techniques described are effective and usually quite at Duke Hospital in our efforts to advance the surgical
safe. Efforts have been made to include techniques that knowledge of endosurgery.
are widely applicable for most advanced laparoscopic Our sincere hope is that this atlas will simplify and orga
surgeons, and given the choiee between complex versus nize surgieal thought for the advanced laparoscopist. The
simple techniques, we tend to use the least complex and operations described should be safe, should not require
shortest operation. Many of the operations, such as the extensive operating time, and should be effective for the
laparoscopic antireflux procedures and laparoscopic diseases described.
gastrostomy and jejunostomy, are spedfically detailed to
Tbeodore N. Pappas
reduce the learning curve for these procedures as much as
Lewis B. Schwartz
possible. Although laparoscopic cholecystojejunostomy
Steve Eubanks
VI
Hartmuth B. Bittner, MD, PhD John P. Grant, MD
Senior Assistant Resident Professor
Department ofS urgery Department ofS urgery
Duke University Medical Center Duke University Medical Center
Durham, North Carolina Duke University Medical School
Durham, North Carolina
Gene D. Branum, MD
Assistant Professor David H. Harpole, Jr, MD
Department ofS urgery Assistant Professor
Emory University School ofM edicine Division of 1boracic Surgery
Emory University Hospital and VA Medical Center Haroard Medical School
Atlanta, Georgia Boston, Massachusetts
Ravi S. Chari, MD Scott H. Johnson, MD
Chief Resident Assistant Professor ofS urgery
Department ofS urgery Division of Cardiothoracic Surgery
Duke University Medical Center Washington University School ofM edicine
Duke University Medical School Christian Northeast Hospital
Durham, North Carolina St. Louis, Missouri
Christine A. Cheng, MD Kevin P. Landolfo, MD
Resident in Plastic and Reconstructive Surgery Assistant Professor ofS urgery
University of Utah Medical Center Department of Surgery
Salt Lake City, Utah Duke University Medical Center
Durham, North Carolina
Bryan M. Clary, MD
Senior Assistant Resident Henry L Laws, MD
Duke University Medical Center
Director ofS urgical Education
Durham, North Caro/ina
Carraway Methodist Medical Center
Clinical Professor of Surgery
Bradley H. Collins, MD
University ofA labama School ofM edicine
Senior Assistant Resident
Birmingham, Alabama
Department of Surgery
Duke University Medical Center
H. K.im. Lyerly, BS, MD
Durham, North Carolina
Associate Professor, General and 1boracic Surgery
Assistant Professor ofP athology
Thomas A. D'Amico, MD
Assistant Professor of Immunology
Fellow in Cardiothoracic Surgery
Duke University Medical Center
Department of Cardiothoracic Surgery
Duke University Medical School
Duke University Medical Center
Durham, North Carolina
Durham, North Carolina
Samuel M. Mahaffey, MD
Andrew M. Davidoff, MD
Assistant Professor
Fellow
Department ofS urgery
Department of Surgery
Duke University Medical Center
University of Pennsylvania
Duke University Medical School
Children 's Hospital of Philadelphia
Durham, North Carolina
Philadelphia, Pennsylvania
James R. Mault, MD
James M. Douglas,Jr, MD
Fellow in Cardiothoracic Surgery
Director of Cardiovascular Surgery
Department ofS urgery
St. joseph Hospital
Duke University Medical Center
Bellingham, Washington
Durham, North Carolina
Steve Eubanks, MD
Cary H. Meyers, MD
Assistant Professor ofS urgery
Director of Surgical Endoscopy Chief Resident in Surgery
Duke University Medical Center Department of Surgery
Duke University Medical School Duke University Medical Center
Durham, North Carolina Durham, North Carolina
vii
WUliam C. Meyers, MD R. Lawrence Reed n, MD
Professor of Surgery Associate Professor of Surgery and Anesthesiology
Department of Surgery Department of Surgery
Duke University Medical Center Duke University Medical Center
Duke University Medical School Duke University Medical School
Durham, North Caro/ina Durham, North Caro/ina
SeanJ. Mulvihill, MD Cary N. Robertson, MD
Associate Professor Associate Professor
Department of Surgery Division of Urology
University of Calijornia, San Francisco, Department of Surgery
School ofM edicine Duke University Medical Center
San Francisco, Calijornia Durham, North Carolina
Lucian Newman m, MD David C. Sabiston, Jr, MD
Gadsden RegionallRiveroiew Regional fames B. Duke Professor of Surgery and Chief ofS taJf
Gadsden, Alabama Duke University Medical Center
Duke University Medical School
Keith T. Oldham, MD Durham, North Carolina
Professor
Department of Surgery and Pediatrics Lewis B. Schwartz, MD
Duke University Medical School Assistant Professor
Duke University Medical Center Department ofS urgery
Durham, North Carolina Pritzker School ofM edicine
University of Chicago
Theodore N. Pappas, MD Chicago, I//inois
Professor of Surgery
Chief, Surgical Seroices Phillip P. Shadduck, MD
Durham VA Medical Center Consultant
Duke University Medical Center Department of Surgery
Duke University Medical School Duke University Medical Center
Durham, North Caro/ina Attending Surgeon
Durham Regional Hospital
Marco G. Patti, MD Attending Surgeon
Assistant Professor Durham Veterans Administration Hospital
Department of Surgery Durham, North Caro/ina
University of Calijornia, San Francisco,
School ofM edicine John T. Soper, MD
San Francisco, Calijornia Professor
Department of Obstetrics and Gynecology
Jeffrey C. Pence, MD Duke University Medical Center
Chief Resident Duke University Medical School
General and 1boracic Surgery Durham, North Caro/ina
Duke University Medical Center
Durham, North Caro/ina James D. St. Louis, MD
Senior Assistant Resident
WUliam N. Peugh, MD, D.PhU Department ofS urgery
C/inical Assistant Professor of Surgery Duke University Medical Center
University of Nevada Duke University Medical School
Las Vegas, Nevada Durham, North Caro/ina
David T. Prlce, BS, MD Christopher R. Watters, MD
Resident in Urology Executive Surgical Center, Inc.
Division of Urology Raleigh, North Caro/ina
Department of Surgery
Duke University Medical Center
Durham, North Caro/ina
viii
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
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
s.
Ravi 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
x
