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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 3  |  Issue : 1  |  Page : 6-15

Laparoscopy and anesthesia: A clinical review


Department of Anaesthesiology, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Web Publication17-Aug-2018

Correspondence Address:
Ramyavel Thangavelu
Department of Anaesthesiology, Pondicherry Institute of Medical Sciences, Ganapathichettikulam, Kalapet, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJL.SJL_3_18

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  Abstract 

Laparoscopy has evolved since as early as 1950 to the present state of being the standard approach for most common surgical procedures. It has gained popularity in clinical practice in view of better cosmetics, lesser postoperative pain, shorter hospitalization, and faster recovery. However, the creation of pneumoperitoneum with laparoscopy is associated with various pathophysiological changes, especially involving the cardiovascular and respiratory systems. Electronic databases were searched to obtain the relevant literature with keywords related to laparoscopy from 1985 to 2016. Ninety-three papers were reviewed. Bibliographies were cross-checked and relevant literature was included. The pneumoperitoneum associated with laparoscopy is found to cause a decrease in cardiac output with an increase in pulmonary and systemic vascular resistance. These changes are mainly due to the increase in abdominal pressure which causes elevation of diaphragm with compression of small and big blood vessels. In the lungs, it causes a decrease in functional residual capacity with impaired pulmonary ventilation and perfusion. Increase in intra-abdominal pressure also perils the splanchnic circulation with a decrease in blood flow to the major abdominal organs. Preoperative assessment requires special attention, especially in high-risk patients. General anesthesia with controlled ventilation has proven to the ideal technique. Various pharmacological agents are used with varying success to attenuate the hemodynamic responses to laparoscopy. This article discusses the various consequences of laparoscopy as well as strategies to counteract them. It is essential for the anesthesiologists to have a good understanding of these changes and intervene at appropriate levels in terms of optimization in the preoperative period and management of hemodynamic changes in the perioperative period for a good surgical and patient outcome.

Keywords: Functional residual capacity, laparoscopy, pneumoperitoneum, pulmonary and systemic vascular resistance


How to cite this article:
Thangavelu R. Laparoscopy and anesthesia: A clinical review. Saudi J Laparosc 2018;3:6-15

How to cite this URL:
Thangavelu R. Laparoscopy and anesthesia: A clinical review. Saudi J Laparosc [serial online] 2018 [cited 2018 Oct 18];3:6-15. Available from: http://www.saudijl.org/text.asp?2018/3/1/6/239213


  Introduction Top


Laparoscopic procedures have greatly improved over the last few years with advances in both anesthetic and surgical techniques. It has revolutionized the surgical field since its introduction in 1950[1] with its advantages of decreased morbidity and early recovery.[2],[3] Although a large number of beneficial effects have been attributed to laparoscopy,[3],[4] they are known to induce specific and potentially deleterious pathophysiological changes to various systems of the body with a wide variety of hemodynamic changes. It is critical for both the surgeon and the anesthesiologist to understand the pathophysiological consequences of laparoscopy [5] and to work collaboratively to achieve optimal outcome. The aim of this article is to provide a comprehensive review on the various physiological changes, benefits as well as complications, perioperative anesthetic considerations, and the various pharmacological agents used to attenuate the hemodynamic changes associated with laparoscopy.


  Literature Search Top


A systematic literature search was done using electronic databases including PubMed and Google Scholar with the help of keywords such as “laparoscopy,” “laparoscopic surgery,” “anaesthesia for laparoscopy,” “hemodynamics in laparoscopy,” and “organ system involvement in laparoscopy.” Searches were conducted by the first author. A total of 93 papers between January 1985 and December 2016 were retrieved which included about 45 randomized control trials, 23 review articles, 5 case reports, and 4 meta-analyses. References were cross-checked and relevant literature was included.


  Benefits of Laparoscopy Top


The benefits of laparoscopic procedures over open surgical procedure come mainly from avoidance of large abdominal incision. The advent of laparoscopy has led to decreased surgical trauma (pain), fewer postoperative complications, and shorter recovery times.[3],[6],[7]

An extensive review on the effects of laparoscopic cholecystectomy in comparison to open procedure was done on various aspects of lung function, namely, spirometric values, arterial blood gases, and respiratory muscle performance.[8] The spirometric variables in the laparoscopy group, namely, forced vital capacity (FVC), forced expiratory volume at 1 s (FeV1), and FEF 25%-75% Forced expiratory flow 25%-75%, were well preserved after 24 h of operation with no major change compared to their preoperative values as against those of open procedure where the values had reduced by almost 50% of the original values. Arterial blood gas and partial pressure of oxygen at 24–48 h after surgical treatment showed reduction, which were significantly greater in open group compared with laparoscopy. Thus, the authors concluded laparoscopic cholecystectomy to be associated with less postoperative derangement of lung function compared to open procedure.

A meta-analysis of laparoscopy versus open colorectal surgeries, which included four randomized control trials and six clinical control trials comprising 1510 patients, was published in 2016. Duration of postoperative hospital stay, time to first bowel movement, total postoperative complication rate, readmission, and mortality were significantly reduced in the laparoscopic surgery group [9] [Table 1].
Table 1: Advantages of laparoscopy

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  Pathophysiological Changes in Laparoscopy Top


Laparoscopic procedure involves inflating the abdomen with carbon dioxide (CO2). This inflation induces certain hemodynamic, metabolic, and respiratory alterations. Most of these changes are usually well tolerated in healthy patients, but it can be different in patients with systemic diseases.[10] The hemodynamic alterations are derived from [Figure 1]:
Figure 1: Cardiovascular/hemodynamic changes to pneumoperitoneum (SVR: Systemic vascular resistance, IVC: inferior vena cava)

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  1. Intra-abdominal pressure (IAP) created by pneumoperitoneum
  2. The presence of an insufflation gas (CO2) that is absorbed by the blood that induces neurohumoral responses
  3. Trendelenburg or anti-Trendelenburg positioning of the patient.


Cardiovascular changes

The major hemodynamic changes that occur due to pneumoperitoneum are a decrease in cardiac output and an increase in arterial pressures/elevation of pulmonary and systemic vascular resistance (SVR).[11],[12],[13]

The pneumoperitoneum increases the abdominal pressure, elevates the diaphragm, and can compress both small and big blood vessels. The vena caval compression and the decreased venous return due to pooling of blood in the legs lead to a decrease in cardiac output by as much as 50%, especially in patients with reverse Trendelenburg or with a low cardiovascular reserve. The diaphragm elevation also raises the intrathoracic pressure with a reduction in cardiac output. The low cardiac output can be compensated in a healthy patient by an increase in the heart rate (HR) and arterial pressure obtaining a stable hemodynamic status.

Most of the reported studies describe an increase in SVR during pneumoperitoneum. However, this increase in SVR cannot be considered as a simple sympathetic reflex response to a decrease in cardiac output.[14],[15]

Various mechanical and neurohumoral factors play a role.[10] Changes in the intrathoracic and transmural right atrial pressure and mechanical stimulation of peritoneal receptors cause release of vasopressin, thus increasing the force and arterial pressures.

Cardiovascular collapse and asystole on induction of pneumoperitoneum have been described and attributed to deep vagal reflexes.[16],[17] If pulmonary ventilation is not enough to eliminate the CO2 absorbed from pneumoperitoneum, hypercapnia appears and the resultant acidosis can depress myocardial function and predispose to arrhythmias [18] [Table 2].
Table 2: Cardiovascular changes with pneumoperitoneum

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Respiratory changes during laparoscopy

The increase in IAP and elevation of diaphragm due to pneumoperitoneum causes decrease in pulmonary compliance by 30%–50% in healthy individuals.[24],[25] Functional residual capacity decreases with gradual development of atelectasis and hypoxemia.[26] Partial pressure of CO2 increases in the blood because of absorption of blood from the peritoneal cavity [1],[27] as well as due to impairment of pulmonary ventilation and perfusion by abdominal distension, patient position (Trendelenburg), and volume-controlled ventilation.[22] However, limiting IAP to 14 mmHg with the patient in a 10°–20° head-down or head-up position does not significantly modify physiological dead space or shunt and is found to be well tolerated in patients without cardiovascular disease [28] [Table 3].
Table 3: Respiratory changes during laparoscopy

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Pneumoperitoneum and regional hemodynamics

Femoral circulation

Increase in IAP and head-up position aggravates femoral venous stasis. This causes an increase in thrombotic events.[28]

Renal

There is usually a decrease in urine output with a decrease in renal plasma flow and GFR. Several renal insufficiency cases have been described associated with an increase in IAP.[32],[33],[34]

Splanchnic circulation

Increase in IAP perils the splanchnic circulation with a decrease in the blood flow to major abdominal organs. Microcirculatory changes in abdominal organs during CO2 pneumoperitoneum were studied in 18 patients undergoing routine laparoscopy. Organ blood flow was measured using a custom-made laser Doppler flow probe at an IAP of 0, 10, and 15 mmHg. It was found that IAP elevation from 10 to 15 mmHg significantly decreased the blood flow in the stomach, jejunum, duodenum, colon, and liver.[35] Splanchnic blood flow decreased with operative time at a constant intra-arterial pressure,[36],[37] thus stressing the fact that laparoscopy surgery with CO2 pneumoperitoneum should be performed at pressure of 12–14 mmHg or lower to avoid microcirculatory disturbances.[28]

Neurological changes

It has been reported that CO2 insufflation can produce adverse cerebrovascular effects, although this has not been extensively studied.[1] Cerebral blood flow increases during pneumoperitoneum in head-down position due to the rise in arterial CO2 pressures.[38] This increase in cerebral blood flow which is usually tolerated could be dangerous in patients with cerebral disease, decreased intracranial compliance, or impaired cerebral physiology. The choice of anesthetic agents also plays a role in minimizing the cerebrovascular responses to laparoscopy.[39] The aim of anesthesia in laparoscopy surgery should include selection of proper anesthetic agent, maintaining normal-to-mild hypercarbia, good oxygenation status, and hemodynamic stability.[40] Any hypotension, hypoxia, and hypercarbia should be avoided. Monitoring of brain tissue oxygenation is a useful tool in clinical setting, especially in high-risk patients providing us the ability to detect any alteration in cerebral oxygenation/perfusion, thus enabling us to intervene at its earliest.


  Anesthesia for Laparoscopy Top


Preoperative assessment

Preoperative assessment for laparoscopy surgery requires special attention to cardiovascular and respiratory systems (because of potential effects of pneumoperitoneum and positioning), especially in obese individuals and those with a low cardiopulmonary reserve.[41] Relative contraindication to laparoscopy should be considered (severe ischemia, valvular heart disease, raised intracranial pressure, and hypovolemia).[42] Cardiac patients with severe left ventricular dysfunction may require intense hemodynamic monitoring. In such patients, gasless laparoscopy or laparotomy may be considered.

Premedication

Premedication for laparoscopic surgery involves H2 blockers or proton-pump inhibitors (especially in patients with increased risk of aspiration)[43] and benzodiazepines (if patient is particularly anxious). Premedication with oral ondansetron was found to significantly reduce the incidence of postoperative nausea vomiting (PONV), especially in gynecological laparoscopy.[44] Anticholinergics are not advocated routinely for laparoscopy.

A prospective double-blind randomized study was conducted by Hong in 2006[45] to evaluate the effects of routine premedication with H2 blockers and prokinetics in patients undergoing ambulatory laparoscopy procedure. Fifteen minutes before induction of anesthesia, one group received 50 mg ranitidine and 10 mg metoclopramide intravenous (IV) and the control group received the same volume of normal saline. When a 14 G nasogastric tube was inserted to aspirate the gastric contents, the mean pH value of the gastric fluid was lower in the control group and the mean aspirated volumes were also higher in the control group, thus revealing those who received ranitidine metoclopramide for prophylaxis before induction to be at lower risk of aspiration pneumonitis in ambulatory laparoscopic procedures. Although anticholinergics are not routinely used, a routine prophylaxis might be helpful in prevention of sinus bradycardia during laparoscopic surgeries. A study done by Aghamohammadi et al.[46] to evaluate the efficacy of atropine sulfate for prevention of bradyarrhythmia during laparoscopic surgery showed a significant decreasing trend in HRs during the operation in patients without atropine prophylaxis. Use of other anticholinergics such as scopolamine patch in patients undergoing gynecological laparoscopy had a significant less incidence of nausea and vomiting during the first 24 h after the surgery.[47] However, another study with preemptive glycopyrrolate 0.2 mg IV given before induction did not significantly reduce the incidence of intraoperative bradycardia compared to the control group (P = 0.4).[48] However, the drug with its antispasmodic properties given before induction was highly effective as a method of improving the quality of recovery and pain [49] (due to tubal spasm following sterilization) after day care laparoscopic sterilization procedures.

Intraoperative

Laparoscopic procedures have been traditionally performed under general anesthesia (GA). Controlled ventilation under GA has been proven ideal to combat the respiratory changes induced by pneumoperitoneum.[50] Induction agents involve the use of rapid and short-acting IV agents such as thiopentone and propofol as well as inhalational agents such as sevoflurane and desflurane, especially for day care laparoscopic procedures.[51],[52] A Cochrane database review from 1982 to 2016 focusing on outcomes of total IV anesthesia (TIVA) versus inhalational agents found no evidence showing clinically meaningful differences in postoperative pain between the two anesthetics. Low-quality evidence suggests that propofol reduces PONV over short term (1–6 h after surgery) after laparoscopic surgery compared with inhalational anesthesia. Low-quality evidence also suggests propofol to prevent an increase in intraocular pressure after pneumoperitoneum and steep Trendelenburg positioning compared with sevoflurane. However, it is unclear that whether this outcome is directly related to clinical evidence of ocular complications during surgery. No studies addressed the secondary outcomes of adverse effects, respiratory or circulatory complications, cognitive dysfunction, length of hospital stay, or costs, thus leaving us with the fact that there is still unclear evidence as to which anesthetic technique is superior as the existing data are scarce and are of low quality. The use of nitrous oxide (N2O) for laparoscopy has been controversial. Although intraoperative awareness is potentially decreased/less with use of N2O, studies in recent literature do not signify any potential advantage of its use.[53] Use of ultra-short-acting opioid analgesic remifentanil has gained popularity for fast-track laparoscopic procedures.[54],[55],[56] Remifentanil was compared with alfentanil in patients undergoing laparoscopic cholecystectomy using TIVA.[57] The remifentanil group reported a significantly lower number of response to intubation and response to first surgical incision as well as a lower hypertensive response and tachycardia during surgical procedures. However, there were no differences in terms of recovery profile/time to awakening. Nondepolarizing muscle relaxants such as atracurium and cisatracurium are used to achieve paralysis under GA. The use of supraglottic airway devices (SGAs) with controlled ventilation can avoid endotracheal intubation in nonobese patients undergoing laparoscopy surgery and also reduce postoperative sore throat.[58],[59] Review on use of SGA for laparoscopic cholecystectomy was done which included a study of ten randomized controlled trials (RCTs), case series, and large prospective observational studies.[60] Most of the studies were focused on gynecological patients. They found evidence stating that laryngeal mask airway (LMA) with a drain channel achieves adequate ventilation for the procedure. Only LMA with gastric access is advised. Although the reported incidence of aspiration associated with the use of LMA in laparoscopic surgery is very low,[60] it is not particularly clarified that the use of LMA is not associated with increased risk of pulmonary aspiration. However, the safest and the most commonly used technique remains GA with endotracheal intubation with maintenance of adequate intravascular volume and end-tidal CO2 (ETCO2) around 35 mmHg by adjustments of tidal volume and respiratory rate [50],[61] [Table 4]. The use of positive end-expiratory pressure remains controversial. Anticholinergics such as atropine should be reserved in cases of bradycardia/sudden changes in vagal tone during laparoscopy. Induction of pneumoperitoneum associated with laparoscopy often induces a large number of hemodynamic changes (prominently increase in pulmonary and SVR with an increase or decrease in HR). Patients with compromised cardiovascular status, obese, old age, and respiratory diseases may have an exaggerated response to pneumoperitoneum. An anesthesiologist aims at controlling and modifying these hemodynamic changes. Various pharmacological agents such as opioids, dexmedetomidine, clonidine, beta-blockers, nitroglycerine (NTG), pregabalin, gabapentin, and MgSO4 have been tried with varying success to provide hemodynamic stability during pneumoperitoneum.[10],[62],[63],[64]
Table 4: Comparison of general and regional anesthesia for laparoscopy

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Dexmedetomidine

Dexmedetomidine, a newer and an upcoming drug, an alpha-2 agonist, acts by inhibiting the release of catecholamines and vasopressin. It is known to provide excellent sedation and analgesia with minimal respiratory depression.[65],[66] The drug as an infusion ranging from 0.2 to 10 μg/kg/h has been used in a large number of studies involving laparoscopy as an anesthetic adjuvant for attenuating the hemodynamic stress response. However, studies with higher doses had more incidence of bradycardia and hypotension.[67] Thus, a loading dose of 0.5–1 μg/kg over 10–15 min followed by a continuous infusion of 0.2–0.5 μg/kg/h was effective with minimal side effects. Dexmedetomidine was also found to reduce the requirements of other anesthetic agents and opioids.[68]

Beta-blockers

Beta-blockers as esmolol, an ultra-short-acting cardioselective beta-1 receptor antagonist has been routinely used in a loading dose of 1 mg/kg over 5 min followed by 0.5 mg/kg/h in attenuation of stress response to laparoscopy.[69] The effect is mediated by blockade of peripheral beta-adrenergic receptors.[70] The other added benefits of esmolol are opioid-sparing effect and a higher urine output (protection against pneumoperitoneum) during intra- and immediate postoperative period in laparoscopic surgeries.[62]

Clonidine

Clonidine, an alpha-2 agonist similar to dexmedetomidine, is a potent antihypertensive drug that suppresses Renin angiotension aldosterone system (RAAS).[11] Clonidine administered in a dose of 4.5 μg/kg was found to decrease mean arterial pressure (MAP) and HR significantly during and after pneumoperitoneum [71] as well as decrease the requirement of isoflurane who were premedicated with clonidine.[72] The plasma rennin levels were also significantly lower in patients treated with clonidine. Thus, clonidine may protect the kidneys from ischemia caused by increased IAP and activated neurohumoral cascade during pneumoperitoneum.[73]

Magnesium sulfate

Administration of magnesium sulfate was found to attenuate the increase in arterial pressure during CO2 pneumoperitoneum. Studies have suggested that magnesium can inhibit catecholamine and vasopressin release in vitro and in vivo.[64],[74] In a study done by Jee et al., MgSO4 given in a dose of 50 mg/kg was found to significantly attenuate the arterial pressure during laparoscopy.[64]

Pregabalin

Pregabalin given as oral premedication was evaluated for hemodynamic stability during pneumoperitoneum. Pregabalin, an antiepileptic drug, is effective in controlling neuropathic component of acute nociceptive pain of surgery by inhibiting voltage-gated calcium channels. The hemodynamic stability provided by oral premedication might enable laparoscopic surgery in obese, hypertensive, and cardiac compromised patients with no risk of postoperative respiratory depression.[75]

Nitroglycerine

The use of NTG in laparoscopic procedures has multiple benefits. The drug as an infusion in the dose of 0.5 μg/kg/min was found to be effective at preventing changes in hemodynamic parameters [76] and IOP induced by CO2 insufflation during laparoscopic cholecystectomy. There was a statistically significant difference in MAP, IOP, and ETCO2 between NTG and saline groups. Furthermore, spasm of  Sphincter of Oddi More Details commonly encountered during laparoscopic cholecystectomy has successfully been treated with IV nitroglycerin.[77] In an animal study of male rats, when animals were pretreated with NTG, the adverse effects of pneumoperitoneum on urine flow rate, urine sodium excretion, GFR, and renal plasma flow were substantially improved, suggesting that adverse effects of pneumoperitoneum are probably related to the interference with the nitric oxide system and could partially be ameliorated by pretreatment with NTG.[78]


  Monitoring Top


Appropriate and standard monitoring techniques must be used to ensure optimal anesthesia care during laparoscopy [6] Hence, electrocardiogram, noninvasive blood pressure, airway pressure monitor, pulse oximeter, ETCO2 monitor,[79] and temperature probe are routinely used. Morbidly obese and patients with poor cardiovascular/respiratory reserve may require additional monitoring in terms of invasive blood pressure [80] and urine output. Airway pressure monitoring is crucial in laparoscopic procedure as a high airway pressure alarm can aid in detection of excessive elevation in IAP. Additional nerve stimulation ensures adequate muscle paralysis which decreases the IAP necessary for abdominal distension.


  Postoperative Course Top


Recovery following a laparoscopic surgery is faster than open procedure mainly due to better preservation of postoperative pulmonary function (FeV1 and FVC), less pain due to reduced tissue trauma of incision, decreased postoperative ileus, and quicker mobilization, thus leading to overall shorter hospital stay and cost.[81] Shoulder tip pain, pain at site, and PONV are few of the postoperative concerns.[82] Complete evacuation of CO2 following the procedure helps minimize the incidence of shoulder tip pain. Preemptive use of serotonin antagonists with single dose of dexamethasone has greatly found to decrease PONV.[44] A multimodal approach to pain management following laparoscopy [83] has been described to be effective with routine use of NSAIDS or COX 2 inhibitors, local anesthetics in the form of incisional and intraperitoneal instillation (reduces neurogenic local inflammation at the trauma site),[84] opioids, and steroids. The addition of gabapentin, clonidine, and NMDA receptor antagonists may also have additional analgesic control.


  Other Choices of Anesthetic Technique Top


GA versus regional anesthesia for laparoscopic surgeries has its own advantages and disadvantages with evidence in the literature [85],[86] [Table 4]. Although the use of regional anesthesia in terms of spinal/combined epidural spinal has been emerging recently as a sole technique with its benefits,[1],[87],[88] it still continues to remain a controversial decision when it comes to laparoscopic surgical procedure.[80],[89] A meta-analysis of RCTs which included relevant articles from January 2000 to December 2016 was carried out to compare spinal anesthesia (SA) versus GA for laparoscopic cholecystectomy.[90] Primary outcome (postoperative pain scores) and secondary outcome (operating time and postoperative complications) were pooled. Seven hundred and twelve patients were treated, 352 in SA group and 360 in GA group. Laparoscopic cholecystectomy under SA was superior to GA in postoperative pain within 12 h in terms of VAS and postoperative complications (PONV and overall morbidity). However, GA group was superior to SA group in postoperative urinary retention. There were no significant differences in the operating time. SA as a sole anesthetic technique was thus feasible and found to be safe for elective laparoscopic cholecystectomy.


  Complications of Laparoscopy Top


Like any other medical procedure, laparoscopy is associated with a set of complications, incidence of which varies significantly depending on the training and experience of the surgeon and the type and complexity of the procedure. The anesthesiologist has to have a knowledge of these to deal with when these potential situations arise [Table 5].
Table 5: Differential diagnosis for complications encountered during laparoscopy

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Inadvertent extraperitoneal insufflations

Insufflations of CO2 can occur in the intravascular, subcutaneous tissue, preperitoneal space, omentum, mesentery, or retroperitoneum due to the misplacement of the Veress needle.[91]

Venous air embolism

Insufflations of CO2 into blood vessel or entrainment of gas into open vessel by venture effect leads to gas embolism.[92],[93] It may manifest with mild-to-severe cardiovascular changes based on the amount of gas entrained into the vascular compartment. Treatment involves resuscitative measures along with attempts to aspirate the gas via central venous catheters.

Subcutaneous emphysema

Needle placement above the abdominal fascia or CO2 leakage around trocar ports may lead to extravasation of gas into the subcutaneous plane leading to subcutaneous emphysema.[58] It is characterized by crepitus over the abdominal and chest wall with increase in ETCO2 and airway pressures.

Pneumomediastinum and pneumopericardium

Subcutaneous emphysema can happen under laparoscopy with accidental CO2 insuffalation into the subcutaneous plane. Extension of this subcutaneous emphysema into the thorax and mediastinum or entry of CO2 through a pre existing defect in the diaphragm may manifest as pneumomediastinum under laparoscopy.[58],[59]

Pneumothorax

Pneumothorax under laparoscopy can occur due to an accidental tear in the visceral peritoneum by the Trocar. A congenital defect in the diaphragm (patent pleuroperitoneal canal) or a spontaneous rupture of pre existing emphysematous bullae may also lead to pnemothorax under laparoscopy. It manifests as increased airway pressures, decrease in oxygen saturation, and significant reduction in cardiac output and blood pressure.[58]

Trocar-associated injuries

Trocar-associated injury of blood vessels, namely, aorta, iliac vessels, inferior vena cava, hepatic artery, and gastrointestinal injuries such as small intestine, colon, duodenum, stomach, and spleen are not uncommon with laparoscopic procedures.[94]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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