Indications and

contraindications of
Laparoscopy
Video laparoscopy is a new tool in the
surgical armentarium. Accordingly, it
offers no new indications for surgery in
established diseases, i.e. strategy of
treatment is the same: laparoscopy
represents a change of tactics aiming for
the same goals of standard surgery viz:
 Safe;
 Low morbidity;
 Maximum chance of cure in case of malignant
disease.
 Indications of surgical
:intervention in general
 Failed medical treatment;
 Occurrence of complications.

N.B.: you could not do an operation

laparoscopically which you could not
do by the open technique.
 Contra-indications of
:laparoscopy

These are medical contra-indications

of pneumoperitoneum (gasless
technique may be still applicable)
 Relative contra-
indications of
:Laparoscopy
 Pregnancy;
 Extensive abdominal adhesions;
 Experience of surgeon versus extent of
pathology;
 Adequacy of available instruments for the
task.
 
Thus in absence of frank contra-indications,
almost all types of surgery can be done
laparoscopically. The question is why
laparoscopy?
 Inherent advantages of
:laparoscopy
 Operative:
o Better visualization in some areas;
o More fine dissection;
o Less blood loss;
o With improvement of learning curve
possibly less operative time.
 
 Inherent advantages of
:laparoscopy
 Post-operative:
o Less pain;
o Less immunosuppression;
o Rapid recovery;
o Less hospital stay and consequently
shorter sick leaves;
o Less post-operative adhesions.
 The driving forces for
laparoscopic
:implementation
 Patient acceptance;
 Industrial and technological drive:
o Money investment;
o Shorter sick leaves.
 Doctor’s acceptance (reviving
general surgery).
:Actual limitations in Iraq

 Relative high cost:

o Hospitals;
o Private patients;
o Third parties.
 Learning curves;
 Medical profession fears:
o Long term follow-up;
o Infection complications.
 State of art of
:indications in Iraq
Diagnostic lap: only contra-indication is
failure to create pneumoperitoneum or
medical contra-indication to
pneumoperitoneum. Relative limitations
are:
o Lack of tactile discrimination;

o Bi-directional vision (angled scopes and

tri-dimensional in progress);
o Assessment of retropeitoneal injuries in
traumatic cases (more or less like open
laparotomy).
 State of art of
:indications in Iraq
 Cholecystectomy: definite
advantage for laparoscopy. When to
stop?
o Lack of progress for 20-30 minutes;
o Non clear anatomy;
o Suspected pathology in CBD with no
available technology or expertise for
laparoscopic exploration of CBD;
o Suspected iatrogenic injuries.
 State of art of
:indications in Iraq
 Appendicectomy: Laparoscopy is
advantageous in:
o Obese;
o Females with suspected diagnosis;
o Athletes.
 State of art of
:indications in Iraq
 Varicocelectomy: Laparoscopy has a
definite advantage in bilateral recurrent
cases.
 Inguinal hernia: definite advantage in
recurrent hernia: relative rapid recovery is
an advantage. Mesh repairs are usually
tension free (transperitoneal or
extraperitoneal) expensed of the mesh
and its fixation.
 Female fertility problems: tubal
patency, adhesolysis, ectopic pregnancy,
endometriosis, ovarian cysts and
 Advanced techniques

o Hiatus hernia: indications for

surgery did not change but probably
patients and internal medicine
acceptance to laparoscopy is better.
To surgeons, laparoscopy offers
better exposure.
 :Advanced techniques

o Peptic ulcer: indications again are not

different: laparoscopy only decreases
parietal complications which are not the
main disadvantages of surgical treatment
of peptic ulcer on elective bases. However,
these complications are appreciable in
cases of perforated peptic ulcer which are
usually acute and over 50% do not need
definitive ulcer surgery latter on:
laparoscopy with proper technology may
be more useful in these conditions.
 :Advanced techniques

o Splenectomy, nephrectomy: possible

with small sized organs. However,
endo-GIA staplers may be needed
during laparoscopic management.
o Laparoscopically assisted colectomy
is possible with several advantage
but however there is a theoretical
fear of port site metastases.
 :Advanced techniques

o Laparoscopic exploration of CBD may

be very useful in operative surprise
of dilated CBD or the possibility of
slipped stones during laparoscopic
cholecystectomy or past history of
jaundice with no present evidence of
it. Otherwise, pre-operative ERCP
combined with laparoscopic
cholecystectomy may be as
effective.
 :Advanced techniques

o Laparoscopic subfascial ligation of

varicosities.
o Laparoscopic face lift.