General Surgery: Laparoscopic and Open Abdominal Procedures

General Surgery: Laparoscopic and Open Abdominal Procedures

General surgery cases make up a large share of the OR schedule. As a surgical technologist, you must know both the open and laparoscopic approaches to common abdominal procedures, understand the sequence of operative steps, and handle instruments safely and correctly every time.

The Surgical Technologist's Role

Your primary responsibility is to maintain a sterile field, anticipate the surgeon's needs, and pass instruments in proper orientation without contaminating yourself, the surgeon, or the field. In laparoscopic cases you also manage the camera, insufflation tubing, light cord, and accessory equipment — all while staying alert to patient safety signals from the anesthesia provider and circulator.

Laparoscopic Principles

Laparoscopic (minimally invasive) surgery uses a camera and long-shafted instruments introduced through small incisions called ports. A trocar is a cannula-and-obturator assembly placed through the abdominal wall to create each port. Before instruments enter the abdomen, the surgeon inflates the peritoneal cavity with carbon dioxide (CO₂) gas — a process called insufflation — to create the working space. The device controlling this is the insufflator, which the circulator or surgical technologist sets to parameters ordered by the surgeon.

Key laparoscopic instruments you will handle include:

• Trocars (with bladed, bladeless, or optical obturators)
• Laparoscope (zero-degree or angled camera scope)
• Graspers (atraumatic and traumatic varieties)
• Endoscopic scissors (hook, curved, or straight)
• Clip applier (fires titanium or polymer clips to ligate structures)
• Suction-irrigation device

Laparoscopic Cholecystectomy: Procedural Sequence

Laparoscopic cholecystectomy (lap chole) is one of the most common elective procedures you will scrub. A standard sequence is:

1. Patient positioned supine; abdomen prepped and draped.

2. Pneumoperitoneum established — typically via Veress needle or open (Hasson) technique at the umbilicus.

3. Camera trocar (usually 10–12 mm) inserted at umbilicus; laparoscope introduced.

4. Additional trocars placed under direct visualization (commonly three more ports in the right upper quadrant and epigastrium).

5. Gallbladder grasped; cystic duct and cystic artery identified and dissected — achieving the critical view of safety before any structure is clipped.

6. Clip applier passed; cystic duct and artery each clipped twice proximally and once distally, then divided with scissors.

7. Gallbladder dissected from liver bed using hook electrosurgery.

8. Specimen retrieved through the umbilical port, often in an endoscopic bag.

9. Ports removed under visualization; fascia closed at larger port sites; skin closed.

Laparoscopic Appendectomy: Key Differences

For laparoscopic appendectomy the patient is often positioned supine with slight left lateral tilt. Three ports are standard. The appendix is identified, the mesoappendix is divided with energy or clips, and the base of the appendix is ligated with endoscopic loops (Endoloops) or a stapler before division. The specimen is removed in a retrieval bag. You should have both a clip applier and an Endoloop available, as the surgeon's preference varies.

Handling Laparoscopic Instruments Safely

• Always pass instruments with the tip closed and pointed downward toward the sterile field — never toward the surgeon's face.
• When loading the clip applier, confirm the cartridge is fully seated before handing it off.
• Keep the laparoscope lens warm and clean; fog can be reduced by warming the scope on a sterile towel or using anti-fog solution.
• CO₂ tubing connects from the insufflator (on the non-sterile side) to the trocar stopcock; the circulator manages the non-sterile end.
• Always account for all clips, needles, and small parts throughout the case.

Open Abdominal Procedures: Incision Types

Open general surgery uses larger incisions. The two you will encounter most often are:

• Midline incision: runs vertically through the linea alba; provides wide exposure; used for exploratory laparotomy, bowel resection, and many urgent cases.
• Pfannenstiel incision: horizontal, just above the pubic symphysis; curved; used for pelvic and lower abdominal access.

For an open case, your instrument sequence typically follows: scalpel → electrosurgical pencil → retractors → dissecting instruments → clamps → suture. Retractors for open abdominal surgery include self-retaining systems (such as Bookwalter or Balfour) and hand-held retractors (Richardson, Army-Navy, Deaver). You must maintain tension on hand-held retractors only as directed and must release them during critical dissection steps to protect tissue.

Instrument-Passing Technique

Correct passing protects both the surgical team and the patient:

• Place the instrument firmly in the surgeon's palm — they should not have to look away from the field.
• Pass clamps with the ratchet closed, rings toward the surgeon's fingers.
• Pass scissors with rings toward the surgeon and blades pointed down.
• Pass suture loaded on a needle holder with the needle pointing in the direction of the surgeon's dominant hand; always announce "sharp" when passing any needled suture.
• Never reach across the surgeon's line of sight.

Patient Safety Priorities

• Maintain strict sterile technique throughout; a break in technique must be reported immediately.
• Perform all instrument, sponge, and sharp counts per facility policy — counts are mandatory before closure.
• Monitor the sterile field for inadvertent contamination, especially during specimen retrieval or when changing from laparoscopic to open approach (conversion).
• Know the signs that indicate conversion to open surgery so you can rapidly open the laparotomy set.
• Electrosurgical equipment must be inspected before activation; insulation defects on laparoscopic instruments can cause thermal injury to bowel.