The laparoscopic cholecystectomy was introduced in 1987, the beginning of explosive growth in minimally invasive surgery.<sup>73 Soper N.J., Brunt L.M., Kerbl K. Laparoscopic general surgery N Engl J Med 1994 ;  330 : 409-419  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> Surgical procedures that historically required days of postoperative hospitalization are now being performed on an ambulatory basis. New procedures are constantly being introduced, spurred on by technologic innovations and advanced instrumentation. Patients have grown to expect minimal pain and rapid hospital discharge, regardless of their underlying medical condition. Older, sicker patients who might have been deemed high risk for the morbidity of an open incision are routinely scheduled for laparoscopic procedures.<sup>28 Jones D.B., Soper N.J., Brunt L.M. , e al. Effect of age and ASA status on outcome of laparoscopic cholecystectomy Surg Endosc 1996 ;  10 : 238

Cliccare qui per andare alla sezione Riferimenti</sup> Anesthesiologists must be prepared to meet the changing demands of patient, surgeon, and procedure. This article highlights the current status of laparoscopic general surgery, emphasizing issues of particular importance to the anesthesiologist. The authors also review the ongoing revolution in ambulatory laparoscopic surgery.

Absolute contraindications to a minimally invasive approach are few:<sup>58 Olson J.A., Moley J.F. Patient selection and preparation Laparoscopic Surgery: Principles and Procedures St. Louis: Quality Medical Publishing (1997).  11

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Obviously, the patient must be able to tolerate general anesthesia. The patient must also be able to undergo a laparotomy if unexpectedly necessary. Because hemorrhage is more difficult to control laparoscopically, the patient should have any coagulopathy corrected prior to laparoscopy. Although relative contraindications can include morbid obesity, pregnancy, peritonitis, extensive adhesions from previous operation, severe cardiopulmonary disease, intestinal obstruction, abdominal aneurysm, or unreducible hernias, many of these relative contraindications are changing as surgeons become more facile and technology improves. For example, many obese patients can undergo operation with a second insufflator and longer trocars.

To date, several laparoscopic procedures have been well accepted, with prospective, randomized studies often resulting in less pain, faster recuperation, improved cosmesis, and rapid return to work and full physical activity, compared with operations requiring a traditional laparotomy. Other procedures, listed here, are commonly performed and gaining acceptance:

Investigational procedures are rarely performed but have promise as technology evolves. Costs of laparoscopic procedures are often difficult to measure. Is it the cost of a trocar or surgical suite time? Is it the benefit to the insurance company, employer, or patient that matters?

Laparoscopy has several inherent limitations. Operating from a monitor requires the surgeon to develop video eye–hand coordination. Furthermore, the surgeon must learn visual cues to compensate for loss of depth perception. Working with elongated instruments through fixed ports restricts movements. Basic surgical skills such as suturing seem laparoscopic feats because of the visual limitations of two-dimensional videosystems and blunted feedback from instruments. Because operating through a videoscope can be a struggle compared with open procedures, fellowships have been established to train and identify the “advanced laparoscopist.”