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FUNDAMENTALS OF LAPAROSCOPIC AND ROBOTIC UROLOGIC SURGERY.pptx

The document comprehensively discusses the fundamentals of laparoscopic and robotic urologic surgery, emphasizing the evolution and efficacy of minimally invasive techniques, which offer advantages like reduced postoperative pain and shorter recovery times. It highlights the importance of preoperative patient evaluation and the considerations for various contraindications, along with enhanced recovery protocols post-surgery. Additionally, it details the technical aspects of accessing the abdominal cavity, instrumentation, and considerations for specific patient conditions during these procedures.

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FUNDAMENTALS OF LAPAROSCOPIC AND ROBOTIC UROLOGIC SURGERY
INTRODUCTION “Diseases that harm require treatments that harm less.”– WILLIAM OSLER • In past 30 years- minimally invasive urology has become predominant. • laparoscopic and robotic procedures have shown equivalent efficacy and acceptable efficiency as well as the distinct advantages of • decreased postoperative pain, • improved cosmesis, • expedited recovery, a shorter hospital stay, • As techniques evolve and mature, in many cases, the cost will be lowered.
PREOPERATIVE PREPARATION
PATIENT SELECTION AND CONTRAINDICATIONS • Initial steps in patient evaluation • meticulous history, focusing on prior surgeries • Physical examination • Detailing the location and extent of all abdominal scars. • Special attention should be given to COPD CARDIAC ARRYTHMIAS ABG Evaluate and treat pre-operatively PFT Reason- physiologic effects of the CO2 pneumoperitoneum hypercarbia and the resulting acidosis
CONTRAINDICATIONS TO LAPAROSCOPY Even if laparoscopic intervention is done in these cases; • careful risk-benefit analysis and • detailed and specific informed consent with the patient is necessary Uncorrectable coagulopathy Intestinal obstruction Abdominal wall infection Hemoperitoneum or hemoretroperitoneum Generalised Peritonitis Suspected Malignant ascites
CONDITIONS WHICH CAN CAUSE POTENTIAL DIFFICULTIES WITH LAPAROSCOPIC AND ROBOTIC APPROACH
MORBID OBESITY Difficulties may include • inadequate length of instruments, • decreased range of motion of trocars and instruments, • need for higher pneumoperitoneum pressures • poor anatomic orientation owing to excessive amounts of adipose tissue • laparoscopic and robotic procedures in morbidly obese patients are certainly more challenging and should be performed later in the surgeon’s career. Lap/Robotic Radical Prostatectomy in Obese Men pathologic outcomes not compromised, greater risk of perioperative complications (26% vs. 5%) (Ahlering et al., 2005) Robotic cystectomy small but statistically significant risk of complication in those with a body mass index (BMI) over 30 (Johar et al., 2013)
EXTENSIVE PRIOR ABDOMINAL OR PELVIC SURGERY • careful consideration must be given to the possible site of Veress needle insertion as well as to obtaining open access with a Hasson style cannula. • The Palmer point (subcostal in the midclavicular line on the left side) is the preferred site for Veress needle insertion when extensive intra-abdominal adhesions are suspected. • In patients with suspected adhesions- Retroperitoneal approach may be preffered over Transperitoneal OR Initiate procedure retroperitoneally then peritoneum entered via retroperitoneal access
PELVIC FIBROSIS • caused by previous peritonitis, pelvic surgery, or extensive endometriosis • Similar problems may be encountered when trying to perform pelvic lymph node dissection in patients who have a hip prosthesis; leakage of the polymethyl methacrylate cement ORGANOMEGALY • (e.g., hepatomegaly or splenomegaly) necessitates a cautious approach when obtaining pneumoperitoneum • Veress needle at safe distance or open access with Hasson Cannula.
ASCITES: BENIGN CAUSE • Increased risk of injury to the bowel because of closer proximity of bowel loops to the anterior peritoneum. • watertight wound closure is required, and a firm wound dressing
Pregnancy • Assess overall risk benefit ratio. • The second trimester is a preferred time for necessary surgery- completion of fetal organogenesis and reduced chance of inducing labor. If surgery is indicated, • Initial access obtained at a safe distance from the fundus of the gravid uterus. • Trocar Placement- more cephalad on the abdominal wall • Prolonged intra-abdominal pressures of 15 mm Hg or greater may result in hypotension (recommended- 8-12 mmhg) • Prolonged CO2 pneumoperitoneum, may result in maternal hypercarbia and acidosis -should be avoided.
HERNIA • A diaphragmatic hernia may result in leakage of a significant amount of CO2 into the mediastinum. • respiratory compromise or cardiac tamponade (e.g., pneumopericardium) • Any uncorrected or surgically corrected umbilical or abdominal wall hernia- rule out these sites for obtaining a pneumoperitoneum. Iliac or Aortic Aneurysm • evaluation by the vascular surgeon • Insertion of accessory trocars must be done under strict endoscopic control to avoid the area of the aneurysm.
BOWEL PREPERATION • For extra/retroperitoneoscopy no bowel prep is typically necessary • Extra/retroperitoneoscopy • Lap/Robotic Transperitoneal- not involving use of bowel segment for reconstruction BOWEL PREPERATION NOT TYPICALLY NECESSARY • if anticipating encountering dense adhesions or • if the surgery involves entering the bowel. FULL MECHANICAL AND ANTIBIOTIC BOWEL PREPARATION
ENHANCED RECOVERY AFTER SURGERY PROTOCOLS • Multimodal and multidisciplinary approach to resolve issues that delay recovery and cause complications. • ERAS Protocols have • shortened hospital stays by 30%, • a reduction in complications by 50%, • a decrease in readmission rates, • Reducing healthcare costs • Emphasis should be placed on the collaboration between surgery and anesthesia • overnight fasting to avoiding solid food 6 hours before surgery • carbohydrate drinks 2 hours before surgery • Meticulous fluid management • Early removal of drains and tubes, early mobilization • the consumption of food and drink on the day of operation.
PREPARARTION OF BLOOD PRODUCTS Procedures with low chance of hemorrhage Lap radical nephrectomy or Nephroureterectomy Rate of transfudion 3-12% Estimated blood loss 106-255 ml Only serum type and screening is sufficient Lap/ Robotic Radical Prostatectomy Transfusion rate 2.5% at experienced centres More extensive Lap/Robotic procedures Partial nephrectomy Radical Cystectomy Radical Nephrectomy + IVC thrombectomy Arrange PRBC before surgery
Instrument checklist before creating Pneumoperitoneum
OPERATING ROOM PATIENT POSITIONING • In the Trendelenburg or lateral position- Tape and security belts applied across the chest and thighs • In lateral position, all bony prominences in contact with the table must be carefully padded • Factors which increase interface pressure • A BMI greater than or equal to 25 • use of a kidney rest • full-table flexion as opposed to half-table flexion • kidney rest was believed to be the most detrimental, and its use beyond 20 to 30 minutes was discouraged
TRENDELENBURG POSITION • For laparoscopic or robotic procedures on the pelvis, the patient can be placed in Trendelenburg position with • the legs on split-leg positioners • or in Allen stirrups • Shoulder supports or braces---risk of brachial nerve injury.
PROPHYLAXIS • Pneumatic compression stockings can be applied for antiembolic prophylaxis • Administration of 5000 units of subcutaneous heparin preoperatively is an option • Foley catheter allows for accurate measurement of urine output, decompresses the bladder to improve visibility and working space.
STRATEGIC PLACEMENT OF OPERATIVE TEAM AND EQUIPMENT • Standard Laparoscopic Cart • Integrated Endoscopy system
Transperitoneal procedure in upper abdomen Surgeon Assistant Anaesthetist Scrub Assistant Suction irrigation Electrocautery Laparoscopic cart/Tower Instrument Table Anaesthesia Equipment Auxillary monitor
RETROPERITONEAL PROCEDURES IN UPPER ABDOMEN Surgeon Assistant Anaesthetist Scrub Assistant Suction irrigation Electrocautery Laparoscopic cart/Tower Instrument Table Anaesthesia Equipment Auxillary monitor
TRANSPERITONEAL AND EXTRAPERITONEAL PELVIC PROCEDURES
ACHIEVING TRANSPERITONEAL ACCESS AND ESTABLISHING PNEUMOPERITONEUM • CLOSED- VERESS NEEDLE • OPEN- HASSON CANNULA VERESS NEEDLE • 70- or 120-mm, 14-gauge, and 2-mm outer diameter • Test the blunt tip to ensure spring retracts easily • 2 points of resistance- abdominal wall fascia & Peritoneum • Assessment of proper needle placement • Negative aspitation • Easy irrigation of saline • Negative aspiration of saline • Positive drop test • Normal advancement test
Sites of needle passage Patient in supine position Head of the bed lowered 10-20 degree Enter at superior border of umbilicus Direct needle towards pelvis Risk of injury to left common iliac, aorta, vena cava Patient in supine position Right or left lower quadrant Colon injury Supine or lateral decubitus Palmer point
OPEN ACCESS TECHNIQUE • Recommended specifically when extensive adhesions are anticipated. • 2 cm semicircular incision at lower edge of umbilicus • The fascia and peritoneum are opened individually- transverse • Two-0 silk traction sutures are placed on either edge of the fascia. • Hasson cannula is advanced through the incision with the blunt tip protruding
Hand Port Access • Pneumoperitoneum can be obtained before or after making the hand port incision • Safest maneuver is to use an open technique and place the hand port into a 6.5- to 7.5-cm open incision and then create the pneumoperitoneum through the hand port. • standard midline or lower quadrant incision at the planned hand- assist site.
RETROPERITONEAL ACCESS AND RETROPERITONEAL SPACE • The Hasson technique is the most commonly used • 2.0- to 2.5-cm transverse incision in the midaxillary line, just below the tip of 12th rib. • Under direct vision, the posterior layer of the lumbodorsal fascia is incised and muscle fibers are split or divided. • Retroperitoneal space is entered under direct vision by making a small incision in the anterior thoracolumbar fascia with an electrocautery blade or, less commonly, by bluntly piercing the fascia digitally
• Two inflations of the balloon are then done—one directed cephalad and the second directed caudad to fully dilate the retroperitoneal space. • Balloon dilation is performed anterior to the psoas muscle and fascia and outside and posterior to the Gerota fascia • BALLOON DILATATION- atraumatically displaces the mobile fat and moves the peritoneum forward relative to the immobile body musculature
PERITONEAL BALLOON DISSECTORS • Commercially available PBD. Available in 2 shapes • Round- for Pelvic Extraperitoneal space • Horizontal/oblong - for retroperitoneal space • Max capacity of 800ml (40 pumps of inflating bulb) • Laparoscope can be inserted into the shaft of the ballon dilator during inflation. • Complications- • Improper placement or balloon rupture • Intramuscular dilatation may result in hernia formation.
Extraperitoneal Access and the Extraperitoneal Space • 1.5- to 2-cm curvilinear incision is made along the inferior umbilical crease. • The anterior rectus sheath is incised vertically for 1.5 cm, and the rectus muscle is separated in the midline to expose the posterior rectus sheath. • surgeon’s index finger positioned posterior to the rectus muscle and anterior to the posterior rectus sheath, gentle tunneling motions till pubic symphysis • fascia transversalis is punctured with the fingertip, and gentle side-to-side digital dissection is performed in the prevesical space, posterior to the pubic bone. • Balloon dilator inserted and inflated.
ACCESS TECHNOLOGY- TROCARS, HAND PORTS AND SINGLE PORT ACCESS.
TROCARS • Nondisposable and disposable trocars are available- one-way valves and multiseal valves. • Multiseal-type valves accommodate the passage of 5-mm and larger instruments without any air leak occurring; • Standard models range from 3 to 20 mm in diameter and 5 to 20 cm in length. • the risk of inferior epigastric injury OR port site herniation is fivefold less with blunt versus sharp trocars
MODIFICATIONS • The Blunt Tip Trocar with Balloon tip • (Medtronic, Minneapolis, MN) has a retention balloon that can be inflated in the peritoneal cavity and then drawn up tightly against the peritoneal side of the abdominal wall. • optical trocar • have a clear plastic tip so that the surgeon can pass an endoscope into the trocar
HAND-ASSIST DEVICES • Common hand-assist devices available are • The GelPort • Endopath Dextrus • Both devices maintain peritoneal gas pressure while allowing for insertion of the surgeon’s hand or surgical instruments into the abdominal cavity • Studies have shown that compared with standard laparoscopy, pain and numbness of the surgeon’s hand, wrist, and forearm and, to a lesser extent, overall fatigue are much greater with use of a hand-assist device
TROCAR PLACEMENT • INITIAL TROCAR PLACEMENT • Surgical site mid-upper abdomen- trocar passed perpendicular to umbilical incision • Pelvic procedures- directed 70 degree caudad
HAND-ASSIST PLACEMENT • placed either as an initial “port,” or as a secondary port depending on the surgeon’s preference. • Every hand port device has a “footprint” that can be drawn on the abdominal wall • plan out the additional trocar sites carefully to avoid interference between the hand port and the instrument ports; • hand port incision site is marked; the length of the incision should correspond to the surgeon’s glove size (e.g., 7 glove size = 7-cm incision) • the use of a brown glove on the intra-abdominal hand is recommended because it does not reflect the light from the laparoscope and thus reduces glare
SECONDARY TROCAR PLACEMENT • inspect entire abdomen -rule out any injury to the underlying viscera. • Number, size, and exact location –depends on the intended laparoscopic procedure • effective triangulation at the surgical site by the endoscope and two working ports. • Reasonable to place the ports in a four-point diamond pattern so that the site of the operation is encircled within the diamond. • Point the port towards the operating field- forceful redirection of the port---widening of the tissue tract--- subcutaneous emphysema. angle between the horizontal plane and the needle drivers 55 Degree angle between the surgeon’s suturing instruments 15-45 Degree
SECONDARY TROCARS DURING HAND ASSISTED APPROACH • secondary trocars can be placed with digital guidance • After a skin incision non-bladed trocar is passed with the other hand and guided by the surgeon’s finger.
LESS- Laparoendoscopic single-site surgery • Two basic methods are used to perform LESS • 1. One technique is to make a 2.5-cm incision, typically periumbilical or transumbilical. • a skin flap can be raised off the abdominal wall fascia • through this single incision, several (two to four) standard 5-mm laparoscopic ports can be placed • most cost-effective technique • 2. commercially available single-site surgery device can be used • TriPort15/TriPort+ (Olympus, Center Valley, PA) and • SILS Port (Medtronic, Minneapolis, MN).
LAPAROSCOPIC INSTRUMENTATION • LAPAROSCOPE AND CAMERA • 0- or 30-degree lenses • available in sizes from 2.7 to 10 mm. • the 30-degree lens provides the surgeon with a more complete view of the surgical field than the 0-degree lens • Deflectable laparoscopes have been developed in which the tip of the endoscope can deflect in four directions up to 100 degrees • ENDO-EYE (Olympus, deflection upto 100 deg) • EndoCAMeleon (Karl Storz, deflection 120 deg) • The camera system consists of a camera and a video monitor. • All currently made cameras can be gas or liquid sterilized,
THREE-DIMENSIONAL SYSTEM • offer the surgeon the distinct advantage of depth perception. • Optimal 3D laparoscopy is performed with a two-lens system that duplicates the two-eye perception of 3D • most commonly used 3D vision system currently in use is the InSite Vision System (Intuitive Surgical), which provides vision for the da Vinci Robotic System. • surgeon maintains a steady, magnified 3D view of the surgical field. • Zero- and 30-degree lenses are currently available.
INSTRUMENTS FOR GRASPING AND BLUNT DISSECTION • Most graspers and dissectors are available in a range from 3 to 12 mm. • either single-action (only one jaw moves during opening) or double-action (both jaws move) tip design • Tip designs include blunt-coarse, pointed (dolphin), straight (duckbill), curved (Maryland), and angled • jaws may be atraumatic or traumatic
INSTRUMENTATION FOR INCISING AND HEMOSTASIS • Laparoscopic scissors, scalpels, • electrocautery, • ultrasonic devices • lasers (CO2, neodymium:yttrium-aluminum-garnet [Nd:YAG], or potassium titanyl phosphate [KTP]) • Cutting of tissue with electrocautery and lasers is achieved when the cell temperature is elevated until the concomitant gas pressure causes the cells to explode • with ultrasonic devices the cutting mechanism is a relatively sharp blade, vibrating at 25 kHz to 55 kHz over an excursion distance of up to 100 μm
Monopolar Electrosurgical Devices • Needle electrodes- fine cuts • Spatula electrodes- blunt dissection and cutting • Hook electrodes (J and L configurations) are of particular value during dissection of vessels because tissue can be pulled away • The thinner the metal tip of the probe is, the higher the density of the electrical current, and the greater the tissue vaporization and apparent “cutting” power. Bipolar Electrosurgical Devices • The extent of coagulative damage is less than with monopolar electrosurgery (1 to 6 mm versus 5 to 7 mm with monopolar current)
LIGASURE VESSEL-SEALING SYSTEM • consists of a 5- or 10-mm grasper-dissector connected to a bipolar radiofrequency generator • less charring and less collateral thermal damage (1–3 mm) • Vessels up to and including 7 mm in diameter appear to be effectively occluded • only one LigaSure application to the structure being sealed is recommended, because multiple applications may weaken the seal • Caiman 5 is a novel device that uses advanced bipolar technology with a pivoting jaw design and closing mechanism with the sealing electrodes distributed in the upper and lower jaws of the instrument. • This mechanism allows for a more homogenous pressure distribution in the jaws. Use of this instrument during partial nephrectomy does not compromise the ability of the pathologist to read the surgical margin
LASER instrumentation • The CO2 laser provides excellent cutting and vaporization of surface lesions and requires a rigid hand piece and probe. • In contrast, the 400- and 600-μm KTP fibers are flexible and allow for noncontact cutting and fulguration. • Nd:YAG laser fibers are also flexible and allow noncontact fulguration and contact cutting. • Holmium laser fibers are also flexible and are used in a contact mode for cutting
ULTRASOUND INSTRUMENTATION • Ultrasonic technology eg- Harmonic scalpel [Ethicon] • electrical energy is transformed into mechanical energy by the use of a piezoelectric crystal system. • Mechanical vibrations produced by this system in the tip of the instrument are capable of causing cavitation, coaptation, coagulation, and cutting in the targeted tissue. • No risk of local thermal damage and tissue charring because of a working temperature lower than 80°C • second benefit is that the depth of penetration is limited to the targeted tissue within a diameter of 1 mm • Disadvantage- • Slower vessel sealing • Metal portion of the shears becomes hot during activation (often more than 200°C compared with the bipolar energy–based devices, which stay below 100°C)
Instrumentation for Suturing and Tissue Anastomosis Needle drivers • Suturing and knot tying are among the most difficult tasks in laparoscopic surgery. Endo Stitch • disposable, 10-mm instrument that facilitates laparoscopic suture placement and knot tying Lapra-Ty Clips • clip acts as a knot, thereby precluding time-consuming intracorporeal laparoscopic knot tying • 3.5-mm clips are made of absorbable polydioxanone and are designed to provide secure anchoring of sutures for up to 14 days
Barbed Suture • knotless barbed suture (V-loc) is an innovative type of suture that can accelerate the placement of sutures and eliminate knot tying. • specifically designed monofilament suture with barbs orientated in the opposite direction of the needle allow the suture to grab the tissue without allowing the suture to slide back • Initially popularized during vesicourethral anastomosis during robotic prostatectomy.
INSTRUMENTATION FOR STAPLING AND CLIPPING STAPLING DEVICES • Endo GIA Universal 12-mm stapler and linear cutting device • requires a 12-mm port and delivers two triple-staggered rows of staples and simultaneously cuts between the rows. • Each staple load cartridge is color coded depending on the size of the staples: • 2.0-mm staples (gray) OR 2.5-mm staples (white) are preferred for vascular (renal vein or renal artery) • 3.8-mm (blue) and 4.8-mm (green) staples are used in thicker tissues (ureter, bowel, bladder) Powered stapler was introduced in 2010. • iDrive Ultra (Medtronic) • Echelon Flex GST System (Ethicon) IMPROVE STABILITY AND MORE PRECISE STAPLING
CLIPPING DEVICES • Clip appliers require 5-, 10-, or 12-mm laparoscopic ports. • In general, they contain occlusive clips ranging in size from 6 to 11 mm. • Electrocoagulation must be avoided in the vicinity of clips placed for occlusion of vessels to prevent conductive tissue necrosis and subsequent clip dislocation. • polymer clips that completely encircle and lock down around a vessel are available • available in four sizes (M, ML, L, and XL). Up to 10 mm of tissue can be ligated through a 5-mm trocar, • 16 mm of tissue can be ligated through a 10-mm trocar. • at least two clips on the stump of the artery and • a 2-mm cuff of artery should be left distal to the clips • Removal of a Hem-o-lok clip is possible using the specified removal instrument should a structure be clipped in error.
INSTRUMENTATION FOR SPECIMEN ENTRAPMENT • size of the tissue and on whether in situ morcellation or intact organ retrieval is planned. LapSac [cook surgical] • made of nylon with a polyurethane inner coating and a polypropylene drawstring. • Up to a 2-kg specimen can be secured
EXITING THE ABDOMEN
PORT REMOVAL AND FASCIAL CLOSURE • Inspect all intra-abdominal entry sites. • Lower pressure to 15 mm hg. • Five millimeter ports are not closed in the adult but are closed in the pediatric patient with a single absorbable suture. • It is recommend that on removal of any of the blunt-tipped ports, the fascia does not have to be sutured, except for ports larger than 10 mm placed in the midline.
PORT CLOSURE DEVICE • consists of a 5-, 10-, or 12-mm cone that has two integrated, hollow, angled, cylindric passages located 180 degrees. • also can be used as a fifth port during nephrectomy to help hold the sack open or to encircle the ureter with a vessel loop through a small stab incision • disposable Endo Close suture carrier (Medtronic)
PHYSIOLOGYC CONSIDERATIONS- CHOICE OF INSUFFLANT CARBON DIOXIDE • most commonly used insufflant • colourless, non-combustible, very soluble in blood, and inexpensive • potential problems (e.g., hypercapnia, hypercarbia, associated cardiac arrhythmias). • In particular, patients with COPD may not be able to compensate for the absorbed CO2 by increased ventilation • stimulates the sympathetic nervous system, which results in an increase in heart rate, cardiac contractility, and vascular resistance. Alternative Gases • Nitrous oxide • Helium • Room air
CHOICE OF PNEUMOPERITONEUM PRESSURE • most commonly selected pressure for performing laparoscopy or robotics is 15 mm Hg. • studies support a pressure of 12 mm Hg as more optimal because this results in no perturbations in cardiac parameters • pressure of 10 mm Hg has been shown to result in a marked reduction in oliguria
CARDIOVASCULAR EFFECTS OF THE PNEUMOPERITONEUM VENOUS FLOW • venous return is reduced because of increased compression of the vena cava from the pneumoperitoneum CARDIAC ARRYTHMIAS • Tachycardia and ventricular extrasystoles may be seen as results of hypercapnia • Peritoneal irritation may lead to vagal stimulation and subsequently to bradyarrhythmias Unreliability of Central Venous Pressure Readings • increasing intra-abdominal pressures may artificially elevate central venous pressure readings owing to an increase in intrathoracic pressure
RESPIRATORY EFFECTS OF THE PNEUMOPERITONEUM Pressure-Mediated Effects • diaphragmatic motion is limited. • advisable to use positive end- expiratory pressure techniques when patients with lung disease undergo general anesthesia for a laparoscopic procedure Non–Pressure-Related Respiratory Effects • head-down position-has an adverse effect on respiration. decreases vital capacity • may cause pulmonary edema in patients with increased left-sided heart pressures • in the head-down position, it is useful to limit fluid administration if possible because it will minimize facial swelling
RENAL EFFECTS OF THE PNEUMOPERITONEUM • to avoid an oliguric state during a laparoscopic procedure, a pressure of 10 mm Hg or less is recommended. • clinically the use of furosemide (Lasix), mannitol (12.5 to 25 g), and dopamine at 2 μg/kg/min can help overcome oliguria.
EFFECTS OF THE PNEUMOPERITONEUM ON MESENTERIC BLOOD FLOW AND INTESTINAL MOTILITY • laparoscopic surgery causes less significant disturbances of the GI motility pattern. • Intestinal perfusion does not change significantly during prolonged pneumoperitoneum at a pressure of 15 mm Hg with CO2
Acid-Base Metabolic Effects of Pneumoperitoneum • May result in hypercarbia and respiratory acidosis • intermittent arterial blood gas sampling should be performed in patients with COPD • IF a rise in end tidal CO2 is noted the • surgeon should decrease the insufflation pressure of CO2 or, if necessary, desufflate the abdomen until the hypercarbia has resolved.
Hormonal and Metabolic Effects During Laparoscopic Surgery • Several hormones (e.g., β-endorphin, cortisol, prolactin, epinephrine, norepinephrine, dopamine) have been noted to increase during laparoscopic surgery Immunologic Effects of Laparoscopic Surgery • laparoscopic procedures in general result in less immunosuppression than do their open counterparts
COMPLICATIONS AND TROUBLESHOOTING
GENERAL PROCEDURAL COMPLICATIONS • Malfunction of Equipment • Complications Related to Obtaining the Pneumoperitoneum • Complications Associated With Closed Access • Preperitoneal Placement • Visceral Injuries • Vascular Injuries • Complications During Open Access (Hasson Technique) • principal risk with the open access is injury to underlying viscera • vascular injury with this approach is distinctly rare
COMPLICATIONS RELATED TO INSUFFLATION AND PNEUMOPERITONEUM • Bowel insufflation • Gas embolism • Barotrauma • Subcutaneous emphysema • Pneumomediastinum, pneumothorax, and pneumopericardium.
Complications Related to Initial “Blind” Placement of the First Trocar After Obtaining a Veress Needle Pneumoperitoneum • Injury to Gastrointestinal Organs • Injury to Intra-abdominal Vessels • best way to handle this complication is to avoid it completely • consider having a “hemorrhage” tray available in the operating room at all times • Injury to the Urinary Tract
INJURY TO URINARY TRACT • Bladder at the time of initial trocar placement • pneumaturia or gross hematuria • diagnosis can be confirmed by retrograde intravesical instillation of indigo carmine diluted with saline • Injury can be repaired laparoscopically with laparoscopic suturing techniques • Extensive defects may require open surgical repair. • Preoperative placement of a urethral catheter to drain the bladder is recommended for all major laparoscopic urologic cases.
COMPLICATIONS RELATED TO PLACEMENT OF SECONDARY TROCARS Bleeding at the Sheath Site • This problem can often be avoided by routinely transilluminating the abdominal wall, especially in the thin patient, before trocar placement Trocar Position–Related Problems • “crossing swords,” “striking handles,” and “rollover.” • best way to handle these situations is to properly place and direct each trocar at the beginning of the case • Last, if trocar interactions become particularly vexing during a procedure, the surgeon should not hesitate to place an additional 5-mm trocar in a more conducive site
COMPLICATIONS RELATED TO THE SURGICAL PROCEDURE Bowel Injury: Electrosurgical- Electrosurgically induced thermal injury may occur through of one of four mechanisms: • Inappropriate direct activation; • coupling to another instrument; • capacitive coupling; • insulation failure • Direct coupling may occur when the active electrosurgical instrument touches another instrument that is in direct contact with other tissue (e.g., bowel) • capacitive coupling occurs when the surrounding charge, which is intrinsic to all activated monopolar electrodes, is not allowed to conduct back to and disperse through the abdominal wall
• Cardiac Arrhythmias and Cardiac Arrest • Changes in Blood Pressure • Aspiration of Gastric Contents • Hypothermia • Bowel injury-mechanical • Vascular Injury • Nerve Injury. • Injury to the Urinary Tract, Spleen, or Pancreas
COMPLICATIONS RELATED TO EXITING THE ABDOMEN • Bowel Entrapment • Bleeding at the Sheath Site
POST-OP COMPLICATIONS • Pain • DVT • Wound infection • Rhabdomyolysis • Incisional hernia • Late post-op complications • Majorly lymphatic complications • Hernia
Port site recurrence • Port Site Recurrence is believed to be multifactorial- (i) technical factors (ii) local wound factors (iii) immune status (iv) biologic tumor behavior.
GASLESS LAPAROSCOPY • Advantages- • adverse effects on cardiopulmonary function and renal blood flow. • Surgeons can safely dissect the renal vessels under direct vision. • Immediate switch to open surgery • Applications in urology- • renal biopsy, varicocelectomy, and pelvic lymph node dissection. • laparoscopy-assisted radical nephrectomy • Suzuki et al. 1997 - retroperitoneal laparoscopy-assisted live donor nephrectomy using the abdominal wall lifting method.
TRAINING AND PRACTICING LAPAROSCOPIC SURGERY • Laparoscopic Training Boxes • Live Animal Models • Cadaveric models • Virtual Reality Trainers • Laparoscopic VR trainers have been shown to improve the skills of trainees, helping to prepare them for better performance during live surgery • VR robotic trainers have been shown to have face, content, and construct validity • Formal Training Programs
Laparoscopic renal biopsy Indications for direct-vision renal biopsy • bleeding diatheses, • morbidly obese patients, • patients with failed prior attempts at percutaneous biopsy • uncooperative patients • Anomalous anatomy • Intraoperative laparoscopic ultrasound using a 10-mm probe can be used to help identify the kidney • aparoscopic biopsy forceps- 1-5 biopsies from cortex • Bleeding controlled by argon beam coagulator/oxidized cellulose.
LAPAROSCOPIC RENAL CYST ABLATION
LAPAROSCOPIC PYELOPLASTY
LAPAROSCOPIC RADICAL NEPHRECTOMY • The intraperitoneal approach is particularly useful for large lesions or • in patients with a tumor in an ectopic or horseshoe kidney. • The retroperitoneal approach is preferred in patients with significant intra-abdominal scarring • Specimens can be extracted either by extending the umbilical trocar site incision or with a small suprapubic incision. • Transvaginal extraction has also been reported
LAPAROSCOPIC RADICAL PROSTATECTOMY • Patient position- dorsal decubitus. slight abduction to permit DRE
LAPAROSCOPIC SURGERY FOR CALCULOUS DISEASE • Lap ureterolithotomy- **large impacted ureteric stones preferably in upper- and mid- ureter • Contraindication- XGP

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FUNDAMENTALS OF LAPAROSCOPIC AND ROBOTIC UROLOGIC SURGERY.pptx

  • 1.
    FUNDAMENTALS OF LAPAROSCOPIC ANDROBOTIC UROLOGIC SURGERY
  • 2.
    INTRODUCTION “Diseases that harmrequire treatments that harm less.”– WILLIAM OSLER • In past 30 years- minimally invasive urology has become predominant. • laparoscopic and robotic procedures have shown equivalent efficacy and acceptable efficiency as well as the distinct advantages of • decreased postoperative pain, • improved cosmesis, • expedited recovery, a shorter hospital stay, • As techniques evolve and mature, in many cases, the cost will be lowered.
  • 3.
  • 4.
    PATIENT SELECTION ANDCONTRAINDICATIONS • Initial steps in patient evaluation • meticulous history, focusing on prior surgeries • Physical examination • Detailing the location and extent of all abdominal scars. • Special attention should be given to COPD CARDIAC ARRYTHMIAS ABG Evaluate and treat pre-operatively PFT Reason- physiologic effects of the CO2 pneumoperitoneum hypercarbia and the resulting acidosis
  • 5.
    CONTRAINDICATIONS TO LAPAROSCOPY Evenif laparoscopic intervention is done in these cases; • careful risk-benefit analysis and • detailed and specific informed consent with the patient is necessary Uncorrectable coagulopathy Intestinal obstruction Abdominal wall infection Hemoperitoneum or hemoretroperitoneum Generalised Peritonitis Suspected Malignant ascites
  • 6.
    CONDITIONS WHICH CANCAUSE POTENTIAL DIFFICULTIES WITH LAPAROSCOPIC AND ROBOTIC APPROACH
  • 7.
    MORBID OBESITY Difficulties mayinclude • inadequate length of instruments, • decreased range of motion of trocars and instruments, • need for higher pneumoperitoneum pressures • poor anatomic orientation owing to excessive amounts of adipose tissue • laparoscopic and robotic procedures in morbidly obese patients are certainly more challenging and should be performed later in the surgeon’s career. Lap/Robotic Radical Prostatectomy in Obese Men pathologic outcomes not compromised, greater risk of perioperative complications (26% vs. 5%) (Ahlering et al., 2005) Robotic cystectomy small but statistically significant risk of complication in those with a body mass index (BMI) over 30 (Johar et al., 2013)
  • 8.
    EXTENSIVE PRIOR ABDOMINALOR PELVIC SURGERY • careful consideration must be given to the possible site of Veress needle insertion as well as to obtaining open access with a Hasson style cannula. • The Palmer point (subcostal in the midclavicular line on the left side) is the preferred site for Veress needle insertion when extensive intra-abdominal adhesions are suspected. • In patients with suspected adhesions- Retroperitoneal approach may be preffered over Transperitoneal OR Initiate procedure retroperitoneally then peritoneum entered via retroperitoneal access
  • 9.
    PELVIC FIBROSIS • causedby previous peritonitis, pelvic surgery, or extensive endometriosis • Similar problems may be encountered when trying to perform pelvic lymph node dissection in patients who have a hip prosthesis; leakage of the polymethyl methacrylate cement ORGANOMEGALY • (e.g., hepatomegaly or splenomegaly) necessitates a cautious approach when obtaining pneumoperitoneum • Veress needle at safe distance or open access with Hasson Cannula.
  • 10.
    ASCITES: BENIGN CAUSE •Increased risk of injury to the bowel because of closer proximity of bowel loops to the anterior peritoneum. • watertight wound closure is required, and a firm wound dressing
  • 11.
    Pregnancy • Assess overallrisk benefit ratio. • The second trimester is a preferred time for necessary surgery- completion of fetal organogenesis and reduced chance of inducing labor. If surgery is indicated, • Initial access obtained at a safe distance from the fundus of the gravid uterus. • Trocar Placement- more cephalad on the abdominal wall • Prolonged intra-abdominal pressures of 15 mm Hg or greater may result in hypotension (recommended- 8-12 mmhg) • Prolonged CO2 pneumoperitoneum, may result in maternal hypercarbia and acidosis -should be avoided.
  • 12.
    HERNIA • A diaphragmatichernia may result in leakage of a significant amount of CO2 into the mediastinum. • respiratory compromise or cardiac tamponade (e.g., pneumopericardium) • Any uncorrected or surgically corrected umbilical or abdominal wall hernia- rule out these sites for obtaining a pneumoperitoneum. Iliac or Aortic Aneurysm • evaluation by the vascular surgeon • Insertion of accessory trocars must be done under strict endoscopic control to avoid the area of the aneurysm.
  • 13.
    BOWEL PREPERATION • Forextra/retroperitoneoscopy no bowel prep is typically necessary • Extra/retroperitoneoscopy • Lap/Robotic Transperitoneal- not involving use of bowel segment for reconstruction BOWEL PREPERATION NOT TYPICALLY NECESSARY • if anticipating encountering dense adhesions or • if the surgery involves entering the bowel. FULL MECHANICAL AND ANTIBIOTIC BOWEL PREPARATION
  • 14.
    ENHANCED RECOVERY AFTERSURGERY PROTOCOLS • Multimodal and multidisciplinary approach to resolve issues that delay recovery and cause complications. • ERAS Protocols have • shortened hospital stays by 30%, • a reduction in complications by 50%, • a decrease in readmission rates, • Reducing healthcare costs • Emphasis should be placed on the collaboration between surgery and anesthesia • overnight fasting to avoiding solid food 6 hours before surgery • carbohydrate drinks 2 hours before surgery • Meticulous fluid management • Early removal of drains and tubes, early mobilization • the consumption of food and drink on the day of operation.
  • 15.
    PREPARARTION OF BLOODPRODUCTS Procedures with low chance of hemorrhage Lap radical nephrectomy or Nephroureterectomy Rate of transfudion 3-12% Estimated blood loss 106-255 ml Only serum type and screening is sufficient Lap/ Robotic Radical Prostatectomy Transfusion rate 2.5% at experienced centres More extensive Lap/Robotic procedures Partial nephrectomy Radical Cystectomy Radical Nephrectomy + IVC thrombectomy Arrange PRBC before surgery
  • 16.
    Instrument checklist beforecreating Pneumoperitoneum
  • 17.
    OPERATING ROOM PATIENT POSITIONING •In the Trendelenburg or lateral position- Tape and security belts applied across the chest and thighs • In lateral position, all bony prominences in contact with the table must be carefully padded • Factors which increase interface pressure • A BMI greater than or equal to 25 • use of a kidney rest • full-table flexion as opposed to half-table flexion • kidney rest was believed to be the most detrimental, and its use beyond 20 to 30 minutes was discouraged
  • 18.
    TRENDELENBURG POSITION • Forlaparoscopic or robotic procedures on the pelvis, the patient can be placed in Trendelenburg position with • the legs on split-leg positioners • or in Allen stirrups • Shoulder supports or braces---risk of brachial nerve injury.
  • 19.
    PROPHYLAXIS • Pneumatic compressionstockings can be applied for antiembolic prophylaxis • Administration of 5000 units of subcutaneous heparin preoperatively is an option • Foley catheter allows for accurate measurement of urine output, decompresses the bladder to improve visibility and working space.
  • 20.
    STRATEGIC PLACEMENT OFOPERATIVE TEAM AND EQUIPMENT • Standard Laparoscopic Cart • Integrated Endoscopy system
  • 21.
    Transperitoneal procedure inupper abdomen Surgeon Assistant Anaesthetist Scrub Assistant Suction irrigation Electrocautery Laparoscopic cart/Tower Instrument Table Anaesthesia Equipment Auxillary monitor
  • 22.
    RETROPERITONEAL PROCEDURES INUPPER ABDOMEN Surgeon Assistant Anaesthetist Scrub Assistant Suction irrigation Electrocautery Laparoscopic cart/Tower Instrument Table Anaesthesia Equipment Auxillary monitor
  • 23.
  • 24.
    ACHIEVING TRANSPERITONEAL ACCESSAND ESTABLISHING PNEUMOPERITONEUM • CLOSED- VERESS NEEDLE • OPEN- HASSON CANNULA VERESS NEEDLE • 70- or 120-mm, 14-gauge, and 2-mm outer diameter • Test the blunt tip to ensure spring retracts easily • 2 points of resistance- abdominal wall fascia & Peritoneum • Assessment of proper needle placement • Negative aspitation • Easy irrigation of saline • Negative aspiration of saline • Positive drop test • Normal advancement test
  • 25.
    Sites of needlepassage Patient in supine position Head of the bed lowered 10-20 degree Enter at superior border of umbilicus Direct needle towards pelvis Risk of injury to left common iliac, aorta, vena cava Patient in supine position Right or left lower quadrant Colon injury Supine or lateral decubitus Palmer point
  • 26.
    OPEN ACCESS TECHNIQUE •Recommended specifically when extensive adhesions are anticipated. • 2 cm semicircular incision at lower edge of umbilicus • The fascia and peritoneum are opened individually- transverse • Two-0 silk traction sutures are placed on either edge of the fascia. • Hasson cannula is advanced through the incision with the blunt tip protruding
  • 27.
    Hand Port Access •Pneumoperitoneum can be obtained before or after making the hand port incision • Safest maneuver is to use an open technique and place the hand port into a 6.5- to 7.5-cm open incision and then create the pneumoperitoneum through the hand port. • standard midline or lower quadrant incision at the planned hand- assist site.
  • 28.
    RETROPERITONEAL ACCESS AND RETROPERITONEALSPACE • The Hasson technique is the most commonly used • 2.0- to 2.5-cm transverse incision in the midaxillary line, just below the tip of 12th rib. • Under direct vision, the posterior layer of the lumbodorsal fascia is incised and muscle fibers are split or divided. • Retroperitoneal space is entered under direct vision by making a small incision in the anterior thoracolumbar fascia with an electrocautery blade or, less commonly, by bluntly piercing the fascia digitally
  • 29.
    • Two inflationsof the balloon are then done—one directed cephalad and the second directed caudad to fully dilate the retroperitoneal space. • Balloon dilation is performed anterior to the psoas muscle and fascia and outside and posterior to the Gerota fascia • BALLOON DILATATION- atraumatically displaces the mobile fat and moves the peritoneum forward relative to the immobile body musculature
  • 30.
    PERITONEAL BALLOON DISSECTORS •Commercially available PBD. Available in 2 shapes • Round- for Pelvic Extraperitoneal space • Horizontal/oblong - for retroperitoneal space • Max capacity of 800ml (40 pumps of inflating bulb) • Laparoscope can be inserted into the shaft of the ballon dilator during inflation. • Complications- • Improper placement or balloon rupture • Intramuscular dilatation may result in hernia formation.
  • 31.
    Extraperitoneal Access andthe Extraperitoneal Space • 1.5- to 2-cm curvilinear incision is made along the inferior umbilical crease. • The anterior rectus sheath is incised vertically for 1.5 cm, and the rectus muscle is separated in the midline to expose the posterior rectus sheath. • surgeon’s index finger positioned posterior to the rectus muscle and anterior to the posterior rectus sheath, gentle tunneling motions till pubic symphysis • fascia transversalis is punctured with the fingertip, and gentle side-to-side digital dissection is performed in the prevesical space, posterior to the pubic bone. • Balloon dilator inserted and inflated.
  • 32.
    ACCESS TECHNOLOGY- TROCARS,HAND PORTS AND SINGLE PORT ACCESS.
  • 33.
    TROCARS • Nondisposable anddisposable trocars are available- one-way valves and multiseal valves. • Multiseal-type valves accommodate the passage of 5-mm and larger instruments without any air leak occurring; • Standard models range from 3 to 20 mm in diameter and 5 to 20 cm in length. • the risk of inferior epigastric injury OR port site herniation is fivefold less with blunt versus sharp trocars
  • 34.
    MODIFICATIONS • The BluntTip Trocar with Balloon tip • (Medtronic, Minneapolis, MN) has a retention balloon that can be inflated in the peritoneal cavity and then drawn up tightly against the peritoneal side of the abdominal wall. • optical trocar • have a clear plastic tip so that the surgeon can pass an endoscope into the trocar
  • 35.
    HAND-ASSIST DEVICES • Commonhand-assist devices available are • The GelPort • Endopath Dextrus • Both devices maintain peritoneal gas pressure while allowing for insertion of the surgeon’s hand or surgical instruments into the abdominal cavity • Studies have shown that compared with standard laparoscopy, pain and numbness of the surgeon’s hand, wrist, and forearm and, to a lesser extent, overall fatigue are much greater with use of a hand-assist device
  • 36.
    TROCAR PLACEMENT • INITIALTROCAR PLACEMENT • Surgical site mid-upper abdomen- trocar passed perpendicular to umbilical incision • Pelvic procedures- directed 70 degree caudad
  • 37.
    HAND-ASSIST PLACEMENT • placedeither as an initial “port,” or as a secondary port depending on the surgeon’s preference. • Every hand port device has a “footprint” that can be drawn on the abdominal wall • plan out the additional trocar sites carefully to avoid interference between the hand port and the instrument ports; • hand port incision site is marked; the length of the incision should correspond to the surgeon’s glove size (e.g., 7 glove size = 7-cm incision) • the use of a brown glove on the intra-abdominal hand is recommended because it does not reflect the light from the laparoscope and thus reduces glare
  • 38.
    SECONDARY TROCAR PLACEMENT •inspect entire abdomen -rule out any injury to the underlying viscera. • Number, size, and exact location –depends on the intended laparoscopic procedure • effective triangulation at the surgical site by the endoscope and two working ports. • Reasonable to place the ports in a four-point diamond pattern so that the site of the operation is encircled within the diamond. • Point the port towards the operating field- forceful redirection of the port---widening of the tissue tract--- subcutaneous emphysema. angle between the horizontal plane and the needle drivers 55 Degree angle between the surgeon’s suturing instruments 15-45 Degree
  • 39.
    SECONDARY TROCARS DURINGHAND ASSISTED APPROACH • secondary trocars can be placed with digital guidance • After a skin incision non-bladed trocar is passed with the other hand and guided by the surgeon’s finger.
  • 40.
    LESS- Laparoendoscopic single-sitesurgery • Two basic methods are used to perform LESS • 1. One technique is to make a 2.5-cm incision, typically periumbilical or transumbilical. • a skin flap can be raised off the abdominal wall fascia • through this single incision, several (two to four) standard 5-mm laparoscopic ports can be placed • most cost-effective technique • 2. commercially available single-site surgery device can be used • TriPort15/TriPort+ (Olympus, Center Valley, PA) and • SILS Port (Medtronic, Minneapolis, MN).
  • 41.
    LAPAROSCOPIC INSTRUMENTATION • LAPAROSCOPEAND CAMERA • 0- or 30-degree lenses • available in sizes from 2.7 to 10 mm. • the 30-degree lens provides the surgeon with a more complete view of the surgical field than the 0-degree lens • Deflectable laparoscopes have been developed in which the tip of the endoscope can deflect in four directions up to 100 degrees • ENDO-EYE (Olympus, deflection upto 100 deg) • EndoCAMeleon (Karl Storz, deflection 120 deg) • The camera system consists of a camera and a video monitor. • All currently made cameras can be gas or liquid sterilized,
  • 42.
    THREE-DIMENSIONAL SYSTEM • offerthe surgeon the distinct advantage of depth perception. • Optimal 3D laparoscopy is performed with a two-lens system that duplicates the two-eye perception of 3D • most commonly used 3D vision system currently in use is the InSite Vision System (Intuitive Surgical), which provides vision for the da Vinci Robotic System. • surgeon maintains a steady, magnified 3D view of the surgical field. • Zero- and 30-degree lenses are currently available.
  • 43.
    INSTRUMENTS FOR GRASPINGAND BLUNT DISSECTION • Most graspers and dissectors are available in a range from 3 to 12 mm. • either single-action (only one jaw moves during opening) or double-action (both jaws move) tip design • Tip designs include blunt-coarse, pointed (dolphin), straight (duckbill), curved (Maryland), and angled • jaws may be atraumatic or traumatic
  • 44.
    INSTRUMENTATION FOR INCISINGAND HEMOSTASIS • Laparoscopic scissors, scalpels, • electrocautery, • ultrasonic devices • lasers (CO2, neodymium:yttrium-aluminum-garnet [Nd:YAG], or potassium titanyl phosphate [KTP]) • Cutting of tissue with electrocautery and lasers is achieved when the cell temperature is elevated until the concomitant gas pressure causes the cells to explode • with ultrasonic devices the cutting mechanism is a relatively sharp blade, vibrating at 25 kHz to 55 kHz over an excursion distance of up to 100 μm
  • 45.
    Monopolar Electrosurgical Devices • Needleelectrodes- fine cuts • Spatula electrodes- blunt dissection and cutting • Hook electrodes (J and L configurations) are of particular value during dissection of vessels because tissue can be pulled away • The thinner the metal tip of the probe is, the higher the density of the electrical current, and the greater the tissue vaporization and apparent “cutting” power. Bipolar Electrosurgical Devices • The extent of coagulative damage is less than with monopolar electrosurgery (1 to 6 mm versus 5 to 7 mm with monopolar current)
  • 46.
    LIGASURE VESSEL-SEALING SYSTEM •consists of a 5- or 10-mm grasper-dissector connected to a bipolar radiofrequency generator • less charring and less collateral thermal damage (1–3 mm) • Vessels up to and including 7 mm in diameter appear to be effectively occluded • only one LigaSure application to the structure being sealed is recommended, because multiple applications may weaken the seal • Caiman 5 is a novel device that uses advanced bipolar technology with a pivoting jaw design and closing mechanism with the sealing electrodes distributed in the upper and lower jaws of the instrument. • This mechanism allows for a more homogenous pressure distribution in the jaws. Use of this instrument during partial nephrectomy does not compromise the ability of the pathologist to read the surgical margin
  • 47.
    LASER instrumentation • TheCO2 laser provides excellent cutting and vaporization of surface lesions and requires a rigid hand piece and probe. • In contrast, the 400- and 600-μm KTP fibers are flexible and allow for noncontact cutting and fulguration. • Nd:YAG laser fibers are also flexible and allow noncontact fulguration and contact cutting. • Holmium laser fibers are also flexible and are used in a contact mode for cutting
  • 48.
    ULTRASOUND INSTRUMENTATION • Ultrasonictechnology eg- Harmonic scalpel [Ethicon] • electrical energy is transformed into mechanical energy by the use of a piezoelectric crystal system. • Mechanical vibrations produced by this system in the tip of the instrument are capable of causing cavitation, coaptation, coagulation, and cutting in the targeted tissue. • No risk of local thermal damage and tissue charring because of a working temperature lower than 80°C • second benefit is that the depth of penetration is limited to the targeted tissue within a diameter of 1 mm • Disadvantage- • Slower vessel sealing • Metal portion of the shears becomes hot during activation (often more than 200°C compared with the bipolar energy–based devices, which stay below 100°C)
  • 49.
    Instrumentation for Suturingand Tissue Anastomosis Needle drivers • Suturing and knot tying are among the most difficult tasks in laparoscopic surgery. Endo Stitch • disposable, 10-mm instrument that facilitates laparoscopic suture placement and knot tying Lapra-Ty Clips • clip acts as a knot, thereby precluding time-consuming intracorporeal laparoscopic knot tying • 3.5-mm clips are made of absorbable polydioxanone and are designed to provide secure anchoring of sutures for up to 14 days
  • 50.
    Barbed Suture • knotlessbarbed suture (V-loc) is an innovative type of suture that can accelerate the placement of sutures and eliminate knot tying. • specifically designed monofilament suture with barbs orientated in the opposite direction of the needle allow the suture to grab the tissue without allowing the suture to slide back • Initially popularized during vesicourethral anastomosis during robotic prostatectomy.
  • 51.
    INSTRUMENTATION FOR STAPLINGAND CLIPPING STAPLING DEVICES • Endo GIA Universal 12-mm stapler and linear cutting device • requires a 12-mm port and delivers two triple-staggered rows of staples and simultaneously cuts between the rows. • Each staple load cartridge is color coded depending on the size of the staples: • 2.0-mm staples (gray) OR 2.5-mm staples (white) are preferred for vascular (renal vein or renal artery) • 3.8-mm (blue) and 4.8-mm (green) staples are used in thicker tissues (ureter, bowel, bladder) Powered stapler was introduced in 2010. • iDrive Ultra (Medtronic) • Echelon Flex GST System (Ethicon) IMPROVE STABILITY AND MORE PRECISE STAPLING
  • 52.
    CLIPPING DEVICES • Clipappliers require 5-, 10-, or 12-mm laparoscopic ports. • In general, they contain occlusive clips ranging in size from 6 to 11 mm. • Electrocoagulation must be avoided in the vicinity of clips placed for occlusion of vessels to prevent conductive tissue necrosis and subsequent clip dislocation. • polymer clips that completely encircle and lock down around a vessel are available • available in four sizes (M, ML, L, and XL). Up to 10 mm of tissue can be ligated through a 5-mm trocar, • 16 mm of tissue can be ligated through a 10-mm trocar. • at least two clips on the stump of the artery and • a 2-mm cuff of artery should be left distal to the clips • Removal of a Hem-o-lok clip is possible using the specified removal instrument should a structure be clipped in error.
  • 53.
    INSTRUMENTATION FOR SPECIMEN ENTRAPMENT •size of the tissue and on whether in situ morcellation or intact organ retrieval is planned. LapSac [cook surgical] • made of nylon with a polyurethane inner coating and a polypropylene drawstring. • Up to a 2-kg specimen can be secured
  • 54.
  • 55.
    PORT REMOVAL ANDFASCIAL CLOSURE • Inspect all intra-abdominal entry sites. • Lower pressure to 15 mm hg. • Five millimeter ports are not closed in the adult but are closed in the pediatric patient with a single absorbable suture. • It is recommend that on removal of any of the blunt-tipped ports, the fascia does not have to be sutured, except for ports larger than 10 mm placed in the midline.
  • 56.
    PORT CLOSURE DEVICE •consists of a 5-, 10-, or 12-mm cone that has two integrated, hollow, angled, cylindric passages located 180 degrees. • also can be used as a fifth port during nephrectomy to help hold the sack open or to encircle the ureter with a vessel loop through a small stab incision • disposable Endo Close suture carrier (Medtronic)
  • 57.
    PHYSIOLOGYC CONSIDERATIONS- CHOICE OFINSUFFLANT CARBON DIOXIDE • most commonly used insufflant • colourless, non-combustible, very soluble in blood, and inexpensive • potential problems (e.g., hypercapnia, hypercarbia, associated cardiac arrhythmias). • In particular, patients with COPD may not be able to compensate for the absorbed CO2 by increased ventilation • stimulates the sympathetic nervous system, which results in an increase in heart rate, cardiac contractility, and vascular resistance. Alternative Gases • Nitrous oxide • Helium • Room air
  • 58.
    CHOICE OF PNEUMOPERITONEUMPRESSURE • most commonly selected pressure for performing laparoscopy or robotics is 15 mm Hg. • studies support a pressure of 12 mm Hg as more optimal because this results in no perturbations in cardiac parameters • pressure of 10 mm Hg has been shown to result in a marked reduction in oliguria
  • 59.
    CARDIOVASCULAR EFFECTS OFTHE PNEUMOPERITONEUM VENOUS FLOW • venous return is reduced because of increased compression of the vena cava from the pneumoperitoneum CARDIAC ARRYTHMIAS • Tachycardia and ventricular extrasystoles may be seen as results of hypercapnia • Peritoneal irritation may lead to vagal stimulation and subsequently to bradyarrhythmias Unreliability of Central Venous Pressure Readings • increasing intra-abdominal pressures may artificially elevate central venous pressure readings owing to an increase in intrathoracic pressure
  • 60.
    RESPIRATORY EFFECTS OFTHE PNEUMOPERITONEUM Pressure-Mediated Effects • diaphragmatic motion is limited. • advisable to use positive end- expiratory pressure techniques when patients with lung disease undergo general anesthesia for a laparoscopic procedure Non–Pressure-Related Respiratory Effects • head-down position-has an adverse effect on respiration. decreases vital capacity • may cause pulmonary edema in patients with increased left-sided heart pressures • in the head-down position, it is useful to limit fluid administration if possible because it will minimize facial swelling
  • 61.
    RENAL EFFECTS OFTHE PNEUMOPERITONEUM • to avoid an oliguric state during a laparoscopic procedure, a pressure of 10 mm Hg or less is recommended. • clinically the use of furosemide (Lasix), mannitol (12.5 to 25 g), and dopamine at 2 μg/kg/min can help overcome oliguria.
  • 62.
    EFFECTS OF THEPNEUMOPERITONEUM ON MESENTERIC BLOOD FLOW AND INTESTINAL MOTILITY • laparoscopic surgery causes less significant disturbances of the GI motility pattern. • Intestinal perfusion does not change significantly during prolonged pneumoperitoneum at a pressure of 15 mm Hg with CO2
  • 63.
    Acid-Base Metabolic Effectsof Pneumoperitoneum • May result in hypercarbia and respiratory acidosis • intermittent arterial blood gas sampling should be performed in patients with COPD • IF a rise in end tidal CO2 is noted the • surgeon should decrease the insufflation pressure of CO2 or, if necessary, desufflate the abdomen until the hypercarbia has resolved.
  • 64.
    Hormonal and MetabolicEffects During Laparoscopic Surgery • Several hormones (e.g., β-endorphin, cortisol, prolactin, epinephrine, norepinephrine, dopamine) have been noted to increase during laparoscopic surgery Immunologic Effects of Laparoscopic Surgery • laparoscopic procedures in general result in less immunosuppression than do their open counterparts
  • 65.
  • 66.
    GENERAL PROCEDURAL COMPLICATIONS •Malfunction of Equipment • Complications Related to Obtaining the Pneumoperitoneum • Complications Associated With Closed Access • Preperitoneal Placement • Visceral Injuries • Vascular Injuries • Complications During Open Access (Hasson Technique) • principal risk with the open access is injury to underlying viscera • vascular injury with this approach is distinctly rare
  • 67.
    COMPLICATIONS RELATED TOINSUFFLATION AND PNEUMOPERITONEUM • Bowel insufflation • Gas embolism • Barotrauma • Subcutaneous emphysema • Pneumomediastinum, pneumothorax, and pneumopericardium.
  • 68.
    Complications Related toInitial “Blind” Placement of the First Trocar After Obtaining a Veress Needle Pneumoperitoneum • Injury to Gastrointestinal Organs • Injury to Intra-abdominal Vessels • best way to handle this complication is to avoid it completely • consider having a “hemorrhage” tray available in the operating room at all times • Injury to the Urinary Tract
  • 69.
    INJURY TO URINARYTRACT • Bladder at the time of initial trocar placement • pneumaturia or gross hematuria • diagnosis can be confirmed by retrograde intravesical instillation of indigo carmine diluted with saline • Injury can be repaired laparoscopically with laparoscopic suturing techniques • Extensive defects may require open surgical repair. • Preoperative placement of a urethral catheter to drain the bladder is recommended for all major laparoscopic urologic cases.
  • 71.
    COMPLICATIONS RELATED TO PLACEMENTOF SECONDARY TROCARS Bleeding at the Sheath Site • This problem can often be avoided by routinely transilluminating the abdominal wall, especially in the thin patient, before trocar placement Trocar Position–Related Problems • “crossing swords,” “striking handles,” and “rollover.” • best way to handle these situations is to properly place and direct each trocar at the beginning of the case • Last, if trocar interactions become particularly vexing during a procedure, the surgeon should not hesitate to place an additional 5-mm trocar in a more conducive site
  • 72.
    COMPLICATIONS RELATED TOTHE SURGICAL PROCEDURE Bowel Injury: Electrosurgical- Electrosurgically induced thermal injury may occur through of one of four mechanisms: • Inappropriate direct activation; • coupling to another instrument; • capacitive coupling; • insulation failure • Direct coupling may occur when the active electrosurgical instrument touches another instrument that is in direct contact with other tissue (e.g., bowel) • capacitive coupling occurs when the surrounding charge, which is intrinsic to all activated monopolar electrodes, is not allowed to conduct back to and disperse through the abdominal wall
  • 74.
    • Cardiac Arrhythmiasand Cardiac Arrest • Changes in Blood Pressure • Aspiration of Gastric Contents • Hypothermia • Bowel injury-mechanical • Vascular Injury • Nerve Injury. • Injury to the Urinary Tract, Spleen, or Pancreas
  • 75.
    COMPLICATIONS RELATED TOEXITING THE ABDOMEN • Bowel Entrapment • Bleeding at the Sheath Site
  • 76.
    POST-OP COMPLICATIONS • Pain •DVT • Wound infection • Rhabdomyolysis • Incisional hernia • Late post-op complications • Majorly lymphatic complications • Hernia
  • 77.
    Port site recurrence •Port Site Recurrence is believed to be multifactorial- (i) technical factors (ii) local wound factors (iii) immune status (iv) biologic tumor behavior.
  • 78.
    GASLESS LAPAROSCOPY • Advantages- •adverse effects on cardiopulmonary function and renal blood flow. • Surgeons can safely dissect the renal vessels under direct vision. • Immediate switch to open surgery • Applications in urology- • renal biopsy, varicocelectomy, and pelvic lymph node dissection. • laparoscopy-assisted radical nephrectomy • Suzuki et al. 1997 - retroperitoneal laparoscopy-assisted live donor nephrectomy using the abdominal wall lifting method.
  • 79.
    TRAINING AND PRACTICINGLAPAROSCOPIC SURGERY • Laparoscopic Training Boxes • Live Animal Models • Cadaveric models • Virtual Reality Trainers • Laparoscopic VR trainers have been shown to improve the skills of trainees, helping to prepare them for better performance during live surgery • VR robotic trainers have been shown to have face, content, and construct validity • Formal Training Programs
  • 80.
    Laparoscopic renal biopsy Indicationsfor direct-vision renal biopsy • bleeding diatheses, • morbidly obese patients, • patients with failed prior attempts at percutaneous biopsy • uncooperative patients • Anomalous anatomy • Intraoperative laparoscopic ultrasound using a 10-mm probe can be used to help identify the kidney • aparoscopic biopsy forceps- 1-5 biopsies from cortex • Bleeding controlled by argon beam coagulator/oxidized cellulose.
  • 81.
  • 82.
  • 83.
    LAPAROSCOPIC RADICAL NEPHRECTOMY •The intraperitoneal approach is particularly useful for large lesions or • in patients with a tumor in an ectopic or horseshoe kidney. • The retroperitoneal approach is preferred in patients with significant intra-abdominal scarring • Specimens can be extracted either by extending the umbilical trocar site incision or with a small suprapubic incision. • Transvaginal extraction has also been reported
  • 84.
    LAPAROSCOPIC RADICAL PROSTATECTOMY •Patient position- dorsal decubitus. slight abduction to permit DRE
  • 86.
    LAPAROSCOPIC SURGERY FORCALCULOUS DISEASE • Lap ureterolithotomy- **large impacted ureteric stones preferably in upper- and mid- ureter • Contraindication- XGP

Editor's Notes

  • #5 hypercarbia and the resulting acidosis may have adverse effects on the myocardium------ exacerbates pre-existing myocardial instability
  • #8 Studies have shown for laparoscopic adrenalectomy and nephrectomy in obese patients that the laparoscopic group had significantly superior outcomes regarding blood loss, resumption of oral intake and ambulation, narcotic analgesic requirements, median hospital stay, and convalescence compared with the open approach
  • #10 polymethyl methacrylate cement
  • #12 The left upper quadrant in the subcostal midclavicular line (i.e., Palmer point) is often the preferred site of access. with subsequent adverse effects on the fetus,
  • #15 educe the catabolic response to surgery, improve insulin resistance and prevent post-operative hyperglycaemia Carbohydrate loading regimens vary by institution. They often include a 100 g oral dose of 12% complex carbohydrate (maltodextrins)
  • #18 highest risk of developing rhabdomyolysis from flank pressure.
  • #19 Shoulder supports or braces should never be used in this position because of the risk of brachial nerve injury.
  • #20 In higher-risk patients, such as the morbidly obese, both may be considered and their use can be continued postoperatively
  • #31 The funnelshaped adapter of the Hasson cannula is advanced until it rests firmly in the incision, and it is then tightened onto the cannula with the attached screw; fixation to the abdominal wall is provided with the fascial sutures that are wrapped around the struts on the funnelshaped adapter of the Hasson cannula
  • #33 Index finger palpation of the belly of the psoas muscle posteriorly and the Gerota fascia–covered inferior pole of the kidney anteriorly confirms proper entry into the retroperitoneal space
  • #46 LAPAROENDOSCOPIC SINGLE SITE SURGERY
  • #48 EndoCAMeleon (Karl Storz, Tuttlingen, Germany). This scope maintains the familiar feel of a standard rigid laparoscope but has a variable-view swing prism that enables the surgeon to change viewing angles from 0 to 120 degrees. An advantage of the EndoCAMeleon is that it has a standard eyepiece, allowing it to be used with most camera systems.
  • #55 Sonicbeat [Olympus] Sonicision [Medtronic]
  • #58 Powered staplers are thought to increase the stability and enable more precise stapling relative to manual staplers
  • #62 bladed trocars are used, the fascia at all 10- to 12-mm port sites should be closed
  • #69 The potential for developing hypercarbia exists during transperitoneal and preperitoneal laparoscopy. CO2 is absorbed from the peritoneal membrane during transperitoneal laparoscopy and from preperitoneal adipose and connective tissue during retroperitoneoscopy and extraperitoneoscopy
  • #85 A- co2 pneumoperitoneum B- Subcutaneous wire lifting C- Peritoneal Planar Lifting D- Peritoneal Planar Lifting with mini Laparotomy Disadvantages- A relatively limited visualization of the operative field. ■ The lifting device may interfere with the use of forceps. ■ Strong traction on the small incision may increase postoperative wound pain
  • #87 Renal biopsy is an important diagnostic tool in the medical evaluation of renal insufficiency, hematuria, and proteinuria, and in the assessment of renal allograft dysfunction Figure 1 ■ Port placement for retroperitoneal laparoscopic renal biopsy. A, location of 10mm port: midpoint between the 12th rib and iliac crest in the PAL; B, location of 5 mm port: Proper identification of the kidney can sometimes be challenging, particularly if there is a large amount of perinephric fat.
  • #89 Endostitch™ (Autosuture Co., Norwalk, CT). The toggle from movement transfers the needle from jaw to faciliate suturing.
  • #91 3- The fatty tissue from the pubic symphysis is removed espousing the endopelvic fascia and the puboprostatic ligaments. The endopelvic fascia is incised. 4- Bladder incision at its junction with the prostate. Dorsal vein complex appears to be ligated just to focus on the incision
  • #93 cases with perinephric adhesions such as xanthogranulomatous pyelonephritis are difficult for the laparoscopic approach