When and How to "Open" in Laparoscopic or Robotic Surgery

Introduction: Surgical training today is all about minimally invasive surgery. With little or no experience and/or confidence in rapid, emergent conversion to an open procedure, how does the surgeon expeditiously do so?

Objectives: The intent of this paper is to help those inexperienced in "open" techniques to quickly recognize the need for same and rapidly open and temporarily control an acute hemorrhage or significant problem requiring more than the tips of laparoscopic instruments.

Methods: The left subcostal or high transverse incision has been used by this author and several others with an experience of several thousand open cases. The author's emergent technique includes a 3-cm mid-line incision from the xiphoid inferiorly, extending into a 135° left subcostal "hockey stick" approximately 12 cm in length, large enough for the surgeon's fist to rapidly apply a tamponading moist lap sponge. Extension of the incision and rectus muscle bleeding is then controlled before proceeding.

Results: This author has used the left subcostal incision in over 4000 bariatric cases over a 30-year career with an incisional hernia and major wound infection rates of less than 1%.

Conclusion: Today, the laparoscope has virtually replaced all open GS visceral techniques which are de-emphasized in surgical training programs. This author's experience demonstrates a rapid fire technique, which will assist the inexperienced open surgeon in dealing with a very treatable acute complication and preventing a long-term disaster with a huge mid-line wound infection, dehiscence, and ultimate hernia.