ABC de Laparoscopía – Dr. Julio Estrada

ABC of Laparoscopy

Guide for undergraduate

This section aims to offer a structured and practical “ABC” of laparoscopic surgery, based on classic general surgery texts, scientific society manuals and international clinical guidelines.

Student guide

Introduction

Laparoscopic surgery has become the standard approach for numerous abdominal pathologies, replacing conventional open surgery in many cases, and for some procedures it has become the gold standard. For medical students and residents, understanding its principles is not only desirable but essential for safe and efficient integration into the surgical team.

This section aims to offer a structured and practical "ABC" of laparoscopic surgery, based on classic general surgery texts, scientific society manuals, and international clinical guidelines. It is not intended to replace formal training, but rather to serve as an entry point and support material for your rotations in general and laparoscopic surgery.

Physiological and technical foundations of laparoscopy

Laparoscopic surgery involves creating a working space within the abdominal cavity using pneumoperitoneum, inserting trocars, and using a camera with a cold light source that projects the image onto a monitor. This transforms direct three-dimensional vision into a two-dimensional view and requires the surgeon to develop specific hand-eye coordination and psychomotor skills.

Pneumoperitoneum is usually performed with carbon dioxide (CO₂) due to its high blood solubility, low risk of gas embolism, and absence of combustion risk. In adult patients, the recommended working pressures are generally between 10 and 15 mmHg, always using the lowest pressure that allows adequate field exposure. Increased intra-abdominal pressure reduces venous return and can impair respiratory function; therefore, hemodynamic and ventilatory monitoring is essential, especially in patients with cardiovascular or pulmonary comorbidities.

Access to the peritoneal cavity can be closed (Veress needle) or open (Hasson technique). The choice depends on the surgeon's experience, body habitus, and history of previous surgeries. The EAES guidelines indicate that the available evidence does not definitively favor one method over the other, provided the technique is performed correctly and with an adequate learning curve.

The laparoscopy tower includes a light source, CO₂ insufflator, camera, monitor(s), and often a video recording system (which I use in all my surgeries). Image quality, monitor positioning, and the surgeon's ergonomics directly influence the precision of movements and, therefore, the safety of the procedure.

The Fundamentals of Laparoscopic Surgery (FLS) program has standardized training in basic skills, including tasks such as scissor cutting, grasping and transferring objects, intracorporeal and extracorporeal suture placement, and coordinated bimanual manipulation. These skills are applicable across most basic laparoscopic procedures.

Anatomy applied to common laparoscopic procedures

Applied anatomy is one of the cornerstones of laparoscopic surgery. The change in perspective and the magnification of the image require students to recognize anatomical landmarks in an environment different from that of open surgery.

Laparoscopic cholecystectomy: This is one of the most common laparoscopic procedures. The main objective is to remove the gallbladder while preserving the integrity of the common bile duct and vascular structures. To achieve this, the concept of “Critical View of Safety (CVS)” is used. This requires: 1). Fully cleaning the triangle hepatocístico de tejido fibroadiposo. 2). Despegar el tercio inferior de la vesícula del lecho hepático. 3).E identificar sólo dos estructuras que entran a la vesícula (arteria cística y conducto cístico) antes de clipar y seccionarlas.
El triángulo hepatocístico está limitado por el conducto cístico, el conducto hepático común y el borde inferior del hígado. Debe diferenciarse del triángulo descrito clásicamente por Calot. La adecuada exposición mediante tracción cefálica y lateral del fondo y el infundíbulo vesicular, así como la disección cuidadosa cercana a la vesícula, son medidas clave para disminuir el riesgo de lesión de la vía biliar.
Laparoscopic appendectomy: Laparoscopic appendectomy allows for complete exploration of the abdominal cavity, which is useful in cases of uncertain diagnosis of right lower quadrant pain. The cecum is usually identified by the convergence of the taeniae coli, which lead to the origin of the appendix. It is essential to recognize positional variations (retrocecal, pelvic, subcecal) and assess the degree of inflammation.

The dissection is usually performed by separating the mesoappendix, controlling the vascular pedicle with clips or energy devices, and ligating the appendiceal base using an endoloop, clips, or mechanical suture. In complicated appendicitis, adequate irrigation of the cavity is important, avoiding contamination of the trocars when removing the specimen.
Laparoscopic inguinal hernioplasty: There are two main approaches: TEP (Total Extraperitoneal) and TAPP (Transabdominal Preperitoneal). Both aim to reinforce the posterior wall of the inguinal canal with a mesh placed in the preperitoneal space. The student should become familiar with landmarks such as Cooper's ligament, the inferior epigastric vessels, the myopectineal orifice, the external iliac vessels, and the area of the triangle of condemnation (triangle of perdition) and the triangle of pain, where important nerves are located.

Knowledge of these risk areas decreases the likelihood of complications such as chronic postoperative pain, bleeding, or vascular injury.

Patient positioning, surgical equipment and ergonomics

The correct positioning of the patient and the surgical team has a direct impact on the safety and efficiency of laparoscopic surgery.

In laparoscopic cholecystectomy, the patient is usually placed in the supine position with a slight leftward tilt (anti-Trendelenburg) to displace the viscera and improve exposure of the gallbladder. In appendectomy, a moderate Trendelenburg position with slight leftward rotation is frequently used to mobilize bowel loops away from the right iliac fossa. In hernioplasty, the supine position with slight hip flexion is common.

The surgeon and assistant should be positioned to allow for comfortable movement, with relaxed shoulders, elbows close to the body, and hands working below heart level. The monitor should be positioned directly in front of the surgeon, at eye level, to reduce neck strain. Ergonomic guidelines for laparoscopy recommend adjusting the table height, the angle of the instruments, and the distance to the monitor to minimize fatigue and improve the precision of movements.

The student must observe and learn these configurations from the beginning of their training, since poor ergonomics contribute to technical errors, tremors, jerky movements and, in the long term, to musculoskeletal injuries of the surgeon.

Basic instruments and power sources

Laparoscopic instruments combine elements of access (trocars), visualization (optics and cameras) and manipulation (forceps, dissectors, scissors, needle holders, staplers, energy devices).

The most commonly used optics are 0° and 30°. The 30° optic allows the viewing angle to be varied by rotating the camera, facilitating the exploration of recesses and structures. Trocars vary in diameter (usually 5 and 10–12 mm) and can be disposable or reusable. The distribution of the trocars should be planned to create adequate triangulation around the target organ.

Energy sources include monopolar and bipolar electrocoagulation, advanced vascular sealing devices, and ultrasonic energy. Each technology has a different safety profile, depth of tissue necrosis, and sealing capacity. Understanding the basic principles is crucial to avoid inadvertent thermal injury to vascular or visceral structures.

The student must become familiar with the tower assembly, connections, camera calibration, focusing, and instrument integrity checks before beginning each procedure. Understanding how to troubleshoot common problems—such as lens fogging, loss of pneumoperitoneum, or insufflation failure—is part of the technical ABCs of laparoscopy.

Safety, complications and key concepts

Patient safety is central to modern laparoscopic surgery. Scientific societies have developed specific recommendations to reduce complications, including biliary, vascular, and visceral injuries.

In laparoscopic cholecystectomy, the systematic use of the Critical View of Safety, respect for anatomical planes near the gallbladder, and early conversion to open surgery in cases of anatomical uncertainty or severe inflammation are strategies strongly supported by clinical guidelines. Furthermore, algorithms have been proposed for the management of biliary tract injuries, emphasizing the importance of intraoperative recognition and early referral to experienced centers when complex injuries are suspected.

In general terms, the complications of laparoscopy can be divided into:

Complications of access: major vascular injuries, hollow viscus injury, extensive subcutaneous emphysema.
Complications of pneumoperitoneum: hemodynamic alterations, hypercapnia, respiratory complications.
Specific complications of the procedure: bleeding, injury to neighboring structures, bile leakage, surgical site infection.

Guidelines from societies such as EAES, SAGES, WSES and Latin American associations emphasize the importance of structured training, the use of simulation, objective assessment of skills and working in trained surgical teams.

For the student, the key message is to understand that laparoscopy is not “just performing the same surgery through small incisions.” It involves changes in physiology, the way anatomy is viewed, and surgical technique. Respect for these principles is essential to contributing to patient safety.

Student Role

The medical student plays an active role in the laparoscopic surgery environment, even before picking up instruments. Their attitude, preparation, and observational skills influence their learning and the team's dynamics.

Recommended responsibilities and attitudes:

Arrive at the hospital on time and check the list of scheduled surgeries.
Read beforehand about the pathology and the procedure that will be performed.
Know the patient's essential clinical data.
Respect asepsis, confidentiality and operating room rules.
Ask questions in a timely and respectful manner, avoiding interrupting critical moments of the procedure.

Frequent mistakes

Common mistakes made by students or first assistants in laparoscopy:

Do not follow the movement of the surgeon's instruments with the camera.
Pulling in the wrong direction, making exposure difficult.
Not anticipating the surgeon's needs (changing the clamp, changing the viewing angle, aspiration).
Getting distracted by the screen or other elements unrelated to the procedure.
Failure to communicate adequately when vision is lost or blood enters the field.

Correcting these errors early, ideally with structured feedback, promotes a faster and safer learning curve. Participation in simulation programs, basic laparoscopy courses, and suturing workshops accelerates the acquisition of technical skills.

How to prepare for your first laparoscopic surgery rotation

The first rotation in laparoscopic surgery often marks a turning point in a student's training. Good preparation increases the likelihood that this experience will be positive and educational.

Practical recommendations:

Study the pathology before watching the surgery. Understanding the procedure's indications and its basic steps will allow you to better interpret what you see on the screen.
Review the anatomy in reliable surgical atlases and videos. Comparing open and laparoscopic procedures helps integrate both perspectives.
Practice basic skills on low-cost simulators, dry boxes, or virtual platforms when available. Hand-eye coordination improves with repeated practice.
Pay attention to your posture and ergonomics from the start. Observe how the surgeon and the team position themselves, and try to replicate these positions when you are allowed to assist.
Ask for feedback. At the end of the procedure, ask what you did well and what you could improve. Constructive criticism is a fundamental part of surgical training.
Maintain an attitude of respect and humility. Each case represents a patient's life and trust; the privilege of being in the operating room implies professional and ethical responsibility.

Laparoscopic surgery will continue to evolve with new technologies, such as robotics, image-guided surgery, and the use of artificial intelligence for intraoperative support. However, the basic principles described in this guide will remain valid as a foundation for any future innovation.

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