Diagnostic Laparoscopy
In abdominal pain of unknown origin, ascites of unknown course, and when appendicitis or gynaecologic disease in fertile women is suspected, it is well established that diagnostic laparoscopy is advantageous. Diagnostic laparoscopy implies introduction of the laparoscopic instruments through the abdominal wall in general anaesthesia and, often, the reason for the patients’ symptoms can be found (or excluded). The definitive treatment can also very often be performed at laparoscopy. The choice of diagnostic laparoscopy instead of open operation depends on many factors such as paraclinical test results, experience of the surgeon, etc. The choice of diagnostic laparoscopy should therefore be discussed with the surgeon regarding pros and cons compared with other diagnostic methods. Diagnostic laparoscopy is also performed routinely in a number of malignant diseases in order to plan the final surgical procedure. During this type of diagnostic laparoscopy it is also possible to include laparoscopic ultrasound scan where the sensitivity for lever metastases particularly is very high. During laparoscopic ultrasound the ultrasound-scanner is mounted on a laparoscopic instrument that is introduced through one of the trocars to the abdominal cavity. Thus, the best final treatment for the patient can be planned and especially the patient will avoid a big laparotomy if cure is not possible with an operative procedure.

Appendectomy
Operation for appendicitis can be performed with laparoscopic technique where the inflamed appendix is removed through one of the trocars. With this technique the patient will experience less pain and less risk of wound infection after operation compared with the open appendectomy. If laparoscopic procedure is difficult for instance because of severe inflammation or other anatomical problems inside the abdomen it can be necessary to convert to open procedure and remove the appendix in the usual manner.

It is a good idea to perform a diagnostic laparoscopy if appendicitis and/or a gynecological disease is suspected, particularly in a fertile woman where the frequency of gynaecologic disease is relatively high. If appendicitis is confirmed, it is possible during the same operation (laparoscopy) to remove the inflamed appendix. In obese patients where the risk of incisional hernia and wound infection is increased it will also be a good idea to aim for laparoscopic removal of the inflamed appendix instead of open appendectomy. Finally, in elderly people, where the incidence of other diseases in the abdomen is slightly increased, it will also be an advantage to perform a diagnostic laparoscopy if appendicitis is suspected.

Cholecystectomy
It is an established fact that operation for gallstone disease, that is removal of the gall-bladder with stones, is best performed with laparoscopic technique. This will reduce a number of otherwise common complications such as wound infection, incisional hernia, post-operative fatigue, as well as reduce the convalescence period after surgery. The operation is performed by introducing four trocars through the abdominal wall and through these trocar’s optics and various surgical instruments are introduced (see Figure 2). The gallbladder is removed from its liver bed and the cystic duct is divided between titanium clips. The cystic artery is also divided between titanium clips and the gallbladder with its contents of stones is removed. In a few per cent of the operations it is necessary to convert to open surgery, especially in severe cholecystitis or if the anatomy is otherwise unclear. Inthis case the patient will receive an incision under the right curvature. The operation inside the abdomen is the same in open as in laparoscopic surgery.

Reflux Disease
In gastroesophageal reflux disease the most commen treatment is pharmacological, most effectively performed with proton pump inhibitors. There are cases, though, where pharmacological treatment is not sufficient or where the patient does not want to take tablets every day. In these cases surgical treatment is a good alternative and using the laparoscopic technique the results are very good with few complications. The operation is typically the Nissen or the Toupét fundoplication, where the fundus of the stomach is dissected from the surrounding tissue (e.g. the spleen), and the fundus is thereafter turned backwards around the oesophagus and fixed to the stomach and/or oesophagus. The Nissen procedure implies a 360º fundoplication and the Toupét procedure involves a 270º fundoplication. During these procedures the angle between the oesophagus and the stomach is changed and this will inhibit the reflux of gastric acid from the stomach to the esophagus. Using conventional open surgical technique, the procedure is quite traumatic and necessitates typically 6–10 days of hospital stay and very often patients get general complications such as pneumonia, wound infection etc. Using laparoscopic technique the operation typically will take about one hour and it can be performed as an outpatient procedure or involving only one day of hospital stay.