Perceived benefits
Reduced post operative pain and analgesic requirement
Reduced operative trauma
Reduced bleeding
Faster recovery, discharge and return to work
Reduced wound infection, seroma and haematoma
Reduced chronic wound pain
Less cardiorespiratory complications
Reduced risk of DVT/PE
Reduced incisional hernia rate
Fewer adhesions and less likely to develop obstruction
Immunological benefits
Better visualisation for the surgeon
Less ileus from reduced handling
Improved cosmesis
Reduced contamination of theatre staff (Hepatitis and HIV)
Interesting for surgeons
Reduced outpatient/social costs

Perceived risks
High risk of co-lateral injury
eg Common bile duct in lap cholecystectomy
Bowel/bladder/vascular injury in hernia surgery
Verres needle injury
Diathermy may lead to organ damage eg late cbd stricture
Increased operating time
Increased costs due to theatre time and equipment
Tumour seeding
Poor quality surgery eg cancer resection
Loss of tactile sensation
Long learning curve
Loss of training opportunity eg appendicitis and inguinal hernia
Some surgeons not able to develop skills

Operations : Now fully accepted
Cholecystectomy ? CBD exploration
Fundoplication
Splenectomy
Nephrectomy
Adrenalectomy
Diagnostic - eg Ca staging, abdo pain

Operations : Still being evaluated
? Appendicectomy
? Inguinal, Femoral, Incisional, Paraumbilical Hernia repair
? Colectomy
? Gastrectomy
? Other gastric surgery eg Obesity surgery

Insuflation technique
Verres needle (closed and blind with risks) / cutdown (Hassan, open and ?safer)

High risk patients likely to benefit most
Elderly
Obese
Cardiorespiratory
Aids
Thoracic

Therapeutic/diagnostic
Abdominal / thoracic
NSAP increased diagnostic accuracy v increased invasion
Small bowel pathology eg Crohns, Aids

Video
2 dimensional normal but depends on surgeon perceiving depth
3 dimensional, experimental and still expensive eg. used with daVinci robot

Gaseous insufflation and Pressures
Keep pressure as low as possible to reduce CVS and respiratory effects
Also reduces post operative pain
14mm mercury intraperitoneal
10 mm mercury extraperitoneal to avoid surgical emphysema
CO2 most commonly used. Helium may be theoretically better but expensive
Usual volume 2.5-3.5 litres intraperitoneally
May cause acidosis with respiratory depression and hypercapnia
Cardiac output may fall as much as 30% due to reduced venous return
Bradycardia most common arrhythmia, easily reversed with atropine
Respiratory depression due to splinting of diaphragm
Other complications may include Pneumothorax, Emphysema, Air embolus

Equipment
Disposable with high cost and reliability v reusable with low cost

Dissection techniques
Blunt - safe but increased bleeding
Scissor +/- diathermy beware diathermy injury
Hook diathermy beware injury
Ultrasound ie Harmonic scalpel , expensive and slow but reduced temperature and less risk of damage
Laser - expensive and largely discounted

Haemostasis techniques
Diathermy , hook/scissor/blunt
Laser
Ultrasound , harmonic scalpel
Titanium clips
Suturing with Roeder loops, extra corporeal knots, intra corporeal knots
Stapling guns eg Endo GIA
Simple pressure as in open surgery

Cost effectiveness
Depends on operating times and use of expensive disposable equipment
Difficult to calculate total costs ie. hospital cost may rise but social costs may fall due to rapid recovery
Balance experience, cost, complications ie expertise

May be an alternative to medical therapy and result in increased use of surgery
Lap Nissen v Medical management of oesophageal reflux
Lap splenectomy v steroids in ITP, AHA etc

Future
Advanced equipment
3d video
Better training
Robotic surgery
Virtual reality
Super MAS ie miniature ports