Special Considerations

The limitations of laparoscopy including loss of direct tactile sensation are overcome by enhanced visualization and increased reliance on visual cues, the use of ultrasound, and indirect palpation with laparoscopic instruments. Current videoscopes permit 15-20x magnification and the diagnostic scope of the examination can be further enhanced with laparoscopic ultrasound. Although direct palpation is not possible, the operating surgeon can indirectly palpate abnormal areas by maneuvering an instrument over the suspected region.

Colonic abnormalities can be evaluated with intraoperative colonos-copy. The use of carbon dioxide as the inflating gas for colonoscopy allows for rapid reabsorption and resolution of bowel distension so this is never an inhibitory factor during laparoscopic surgery.3

Recent technologic advances in laparoscopic ultrasound probes with four-way steerable scanning head, integrated biopsy system, and color flow mapping allow for full evaluation of intra-abdominal organs such as the liver and the retroperitoneum. Integrated biopsy systems, such as the one provided by Bruel & Kjaer, allow for real-time ultrasound targeted TRU-Cut biopsies. Intraoperative liver ultrasound is a proven diagnostic modality. This has been clearly demonstrated in patients with known liver metastases where liver ultrasound at the time of liver metastasectomy often identifies additional lesions that alter the surgical plan.4,5 However, the use of routine liver ultrasound in nonmeta-static disease is less established. In a study of 63 patients undergoing diagnostic laparoscopy before curative colorectal resection, two patients were noted to have hepatic lesions not previously picked up on computed tomography scan.6 In another study of 33 patients that underwent preoperative laparoscopy and liver ultrasound, one patient was found to have liver metastases missed by preoperative computed tomography scan.7 Although not conclusively proven, it is reasonable to perform liver ultrasound in high-risk patients to assess for metastatic disease because the procedure is noninvasive and relatively quick.

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