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Concept laparoscopic surgery
- 1. Concept of LaparoscopicSurgery
- 2. Learning objectives • Terminologies •Laparoscopy – Various methods – Advantages – Limitations – Pre-requisite- workup, setup & tools – General principles
- 3. Terminologies • Minimal AccessSurgery(MAS) – surgical innovation that aims to accomplish surgical therapeutic goals with minimal somatic and psychological trauma. – reduced wound access trauma, as well – less disfiguring than conventional techniques • Minimal Invasive Surgery(MIS)
- 4. Laparoscopy: History • Firstlaparoscopic cholecystectomy – – done by Muhe of Germany in 1985 & by Mouret in Lyon in 1987 – in USA in 1988, by McKeran and Saye – In India, by Professor TE Udwadia • First laparoscopic appendicectomy – – done by Semm as prophylaxis – by Schreiber in 1987 for acute appendicitis
- 5. Laparoscopy: Advantages • Relativelyless painful – Trauma of access is very less • Shorter hospital stay and early return to work • Faster postoperative recovery • Better visualization of the anatomy, – better approach for dissection and visualization of other parts of abdomen for any other pathology • Instrumental access to different locations is many times better • Minimal scar
- 6. Laparoscopy: Limitations • Relativecontraindications: – Compromised cardiac status – Peritonitis – Previous abdominal surgeries. – Bleeding disorders. – Morbid obesity. – Third trimester pregnancy. – Portal hypertension.
- 7. Laparoscopy: Limitations.. • Limitationsof MIS: – Reliance on remote vision and operating – Loss of tactile feedback – Dependence on hand–eye coordination – Difficulty with haemostasis – Reliance on new techniques – Extraction of large specimens
- 8. Laparoscopy: Prerequisites • Overallfitness: cardiac arrhythmia, emphysema, medications, allergies • Previous surgery: scars, adhesions • Body habitus: obesity, skeletal deformity • Normal coagulation • Thromboprophylaxis • Informed consent • Instruments used
- 9. Laparoscopy: Prerequisites.. • Instrumentsused: – Laparoscope – Camera – Cold light source – Video monitor – C02 insufflator – Surgical instruments: • Long fine dissectors • Hooks & spatulas • Clip applicators • Needle holders • Endostaplers • Veress needle • Suction-irrigation apparatus • Trocars • Reducers
- 13. Laparoscopy: Prerequisites.. • Preparation: –General anesthesia – Prevention of inadvertent injuries – Pressure bandages/ cuffs – Position of patient • Strapping • According to surgery • Reverse trendelenberg position
- 14. Laparoscopy: Technique • Access: –Open vs. closed method • Creation of pneumoperitonium • Visualisation • Additional ports – Triangulation – Ergonomics • Sometimes additional incision required
- 15. Laparoscopy: Physiologic changes •CO2 causes – hypercarbia, acidosis and hypoxia. • Pneumoperitoneum – decreases the venous return – increases the arterial pressure • It compromises the respiratory function – by compressing over the diaphragm
- 16. Laparoscopy: Complications • CO2narcosis and hypoxia • Sepsis-subphrenic abscess, pelvic abscess, septicaemia. • IVC compression. • Bleeding. • Leak from the site, e.g. bile leak. • Organ injury during insertion of ports. • Subcutaneous emphysema and pneumomediastinum.
- 17. Laparoscopy: Complications.. • Gasemboli, though is rare but fatal. • Postoperative shoulder pain due to irritation of diaphragm. • Cardiac dysfunction due to decreased venous return. • Injury to the abdominal wall vessels and nerves. • Cautery burn to abdominal structures. • Abdominal wall hernias. • Wound infection. • Mortality-0.5%.
- 18. Laparoscopy: General principles •Core principles of MAS summarized by acronym I VITROS – Insufflate/create space – Visualise – the tissues, anatomical landmarks and the – environment for the surgery to take place – Identify – Triangulate – surgical tools (such as port placement) to optimise the efficiency of their action, and ergonomics by minimising overlap and clashing of instruments – Retract – and manipulate local tissues to improve access and gain entry into the correct tissue planes – Operate – incise, suture, anastomose, fuse – Seal/haemostasis.
- 19. Laparoscopy: Procedures • Basicsurgeries: – Laparoscopic cholecystectomy. – Laparoscopic appendicectomy. • Advanced surgeries: – Hernia repairs, splenectomy, fundoplication, vagotomy & GJ, Colectomy: APR, LAR, hysterectomy, urologic procedures, thoracic/thyroid/paediatric surgeries etc.
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