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minimal access surgery and ergonomics of laparoscopy
- 1. PRINCIPLES OF MINIMAL ACCESSSURGERY DR. S.K. Kaushik S3 unit under guidance of DR.A.KISHORE BABU M.S.( Professor) DR.PREMNATH M.S.( Associate professor) DR.SRINIVASA M.S. ( ASST.Professor) DR.ABHILASH M.S ( ASST.Professor) DR.KAVYA M.S. (ASST. Professor)
- 2. Outline • Definition • History •Minimal Access Approaches • Advantages. • Limitations • Perioperative Planning
- 3. Definition • Modern technologyand surgical innovation that aims to accomplish surgical therapeutic goals with minimum somatic and psychological trauma. • Reduced wound access trauma • Less disfiguring • Cost effective
- 4. History • 1st experimentallaparoscopic procedure:- Kelling in 1901. • 1st thoracoscopy:- Jacobeus in 1910 ( cystoscope). • • Steptoe:- laparoscopy for treatment of infertility. • • Mouret :- 1st video-laparoscopic cholecystectomy in 1987.
- 5. Minimal Access Approaches •Laparoscopy • Thoracoscopy • Single incision minimal access surgery • Endoluminal endoscopy and natural orifice surgery(NOTES) • Perivisceral endoscopy • Arthroscopy and intra-articular joint surgery • Hybrid minimal access surgery
- 6. LAPAROSCOPY • Rigid endoscopeis introduced through port into peritoneal cavity • Pneumoperitoneum created - position : supine with arms by side , trendelenburg or reverse trendelenburg -site : infra or supraumbilical region -types : open and closed methods CLOSED ( Veress needle technique) : insert veress needle into peritoneal cavity and confirm placement by saline drop test or pressure reading OPEN (Hasson technique) : blunt trocar inserted under direct vision after giving incision Target pressure : 12 to 15mmhg ( 8 to 10 mmhg in case of high risk or cardiopulmonary pateients)
- 8. Gases used : •Carbon dioxide : most common , non inflammable, highly soluble in blood ( low risk of emboli) - may cause respiratory acidosis, hypercapnia, bradycardia ( vagal response) •Nitrous oxide : supports gas combustion,gas emboli •Room air : poorly absorbed, gas emboli •Oxygen : highly flammable , never used for insuffulation •Helium : non inflammable but poor solubility thereby more chances of emboli COMPLICATIONS : injury( to bowel,bladder,blood vessels), gas emboli,sub cutaneous emphysema,preperitoneal insuffulation
- 10. THORACOSCOPY •Rigid endoscope introducedthrough incision between ribs to gain access to thorax. •In general no gas suffulation as operating space held rigid by thoracic cavity •Specific cases like mediastinal tumor resection and diaphragmatic surgeries (5-8mmhg)
- 12. SINGLE INCISION MINIMALACCESS SURGERY SILS (single incision laproscopic surgery): • all instruments through multiple ports through single incision at umbilicus • reduces the port site bleeding,port site hernia • adopted for hernia and gall bladder surgery etc UNIPORTAL THORACIC SURGERY
- 15. ENDOLUMINAL ENDOSCOPY ANDNATURAL ORIFICE SURGERY •Flexible or rigid endoscope introduced into hollow organs or systems urinary tract upper and lower gastrointestinal tract respiratory tract vascular system NOTES(Natural orifice translumenal endoscopic surgery)
- 18. PERIVISCERAL ENDOSCOPY •Mediastinoscopy,retroperitoneoscopy (retroperitoneal approachto aorta,kidney,lumbar sympathetic chain) • subfascial endoscopic ligation of incompetant perforators
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- 22. HYDRID MINIMAL ACCESSSURGERY •Flexible and staright stick endoscope •open and endoscopic surgery TOTALLY ENDOSCOPIC HYBRID APPROACH • Endo and extra luminal endoscope • ABDOMEN : laparo-endoscopic approach of biliary lithiasis,colonic polyp excision,urological procedures (pyeloplasty and donor nephrectomy) • THORACIC: Navigation bronchoscope with placement of fiducial markers
- 23. OPEN AND ENDOSCOPICHYBRID APPROACH • HALS(Hand assisted laproscopic surgery):hand or forearm placed through minilaprotomy incision while pneumoperitoneum is maintained • palpate organs or tumors, reflect organs atraumatically, retract structures, blunt dissection along tissue and finger pressure to bleeding point
- 26. Avantages of MinimalAccess Surgery
- 27. Limitations of MinimalAccess Surgery
- 28. ROBOTIC SURGERY • Robot: mechanical device that performs automated physical tasks according to direct human supervision , a predefined program or a set of guidelines , using artificial intelligence • Robotic surgical systems : TELEOPERATED(master - slave) system: surgeon performs operation via robot and it’s instruments through televisual computerised platform ACTIVE OR SEMIACTIVE SYSTEM: robots completes pre programmed surgical task
- 30. HISTORY • CT guidedbiopsy in 1985 using PUMA 560 system ( programmable universal machine for assembly ) • ROBODOC pre programmed active robot that enabled precise preparation of femoral implant cavity during hip replacement • In 1992 AESOP ( Automated Endoscopic System for Optimal Positioning) which mounted endoscopic camera on single robotic arm and is controlled by surgeon by voice command • ZEUS in 1996 master-slave teleoperated system • da Vinci surgical system in 2000 ( da Vinci Xi 2014)
- 33. ADVANTAGES • VISION: 3dhd imaging, improves stereoscopic vision with depth perception • Manoeuvrability : improved with seven degree of freedom • Improves dextrity and filter out tremors • Improves ergonomic environment for surgeon
- 34. DISADVANTAGES • Costly • Increasedoperating time • More learning curve
- 35. DIRECT ROBOTIC SYSTEMSAND HYBRID ROBOTIC SURGERY • tremor suppression robots • active guidance systems • articulated mechanotronic devices • force control systems • haptic feedback devices
- 36. PERIOPERATIVE PLANNING FORMINIMAL ACCESS SURGERY • PREPARATION OF THE PATIENT
- 37. HISTORY • coagulation disordersas the options for hemostasis are limited • history of surgery in same area for adhesions • previous oncological treatment as it creates hostile surgical environment
- 38. EXAMINATION • Cardiac evaluationas insuffulation of chest and abdomen may cause arrhthymias • severe chronic obstructive airway disease and ischemic heart disease are contraindicated • Morbid obesity -special instrumentation and trochars needed • low bmi and small body habitus challenging for ports placement • spinal deformities difficult in positioning
- 39. PROPHYLAXIS AGAINST THROMBOEMBOLISM •Reverse trendelenburg position in laproscopy and prolonged duration are risk factors for deep vein thrombosis • low molecular weight heparin,anti thrombotic stockings ,pneumatic calf compressions in prolonged surgeries
- 40. URINARY CATHETERS ANDNASOGASTRIC TUBES • Recent times mostly omitted • check whether pt is on fasting and emptied bladder
- 41. INFORMED CONSENT • Natureof procedure • risks • alternative procedures • explanatory booklet • conversion to open procedures • addressing patient questions and requests • complications :shoulder tip pain,minor surgical emphysema and visceral injury(rare and serious)
- 42. THEATER SET UPAND TOOLS • Key to efficiency • modern theaters : movable booms for diathermy,laproscopic equipment,carbon dioxide supply,flow monitor,appropriate audiovisual kits,high or ultra high definiton monitors • Image quality :camera and lens technologies , automatic focusing and charge coupled devices for different level of brightness • Efficient team work
- 44. General intraoperative principles •Unique set of procedure steps • methods of creating pneumo peritoneum • site of trochar placement in redo surgery • larger and longer instruments in obese patient
- 45. OPERATIVE PROBLEMS Intraoperative perforationof a viscus or vascular injury • Emergency conversion is required • blood loss may lead to hemodynamic instability • avoided by surgical experience,education,patient selection and preparation
- 46. BLEEDING • Most commoncause for conversion to open surgery • RISK FACTORS: - liver diseases (cirrhosis, autoimmune liver disese) - patient on anticoagulants -coagulation defects -inflammatory conditions like acute cholecystitis,diverticulitis
- 47. • BLEEDIN FROMORGANS DURING SURGERY: - due to excessive retraction - surgicel(absorbable fibrillar oxidised cellulose),tissue glues
- 48. • Bleeding fromtrochar site: -applying upward pressure, lateral pressure by torchar itself, diathermy -Endoclose used to apply transabdominal sutures -mass ligation of vessels around port -foley ballon catheter
- 50. ELECTROSURGICAL INJURIES • Inadveretenttouching or grasping of tissue during current application • direct sparkling from diathermy probe • insulation breaks in laproscopic or robotic instruments • current passage from recently coagulated tissue bipolar is safer and preferred to monopolar
- 52. POST OPERATIVE CARE •NAUSEA : responds to antiemetics and settels with in 12to24 hrs • SHOULDER TIP PAIN : Referred from diaphragm , worst 24hrs after operation and settels within 2to3 days • PORT SITE PAIN AND NUMBNESS: -worse if hematoma is formed -may be a sign of infection -herniation through port site
- 53. • ANALGESIA :depends on patient and procedural factors • ORO OR NASOGASTRIC TUBES:before patient regain consciousness • ORAL FLUIDS: resume fluids by 4 to6 hrs after operation • ORAL FEEDING: light meal after 4to6 hrs of operation • URINARY CATHETER: before patient regain consciousness (short procedures <4hrs urinary catheter is not needed)
- 54. • DRAINS: Outputshould be monitored continuous blood loss from drain is an indication for re exploration •MOBILITY: as soon as they recovered from anaesthesia •SKIN SUTURES : if non absorbable removed after 7 to 10 days
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- 56. AUGMENTED REALITY • Fusionof projected computerised images with a real environment • application of real time imaging or other data overlaid via computer processing software onto surgical field • EXAMPLES: use of INDOCYANINE GREEN for immunofluorescent localisation of tumors , vascular , bronchial, lymphatic structures when bound to plasma proteins indocyanine green emits light with peak wavelwnth of 820 to 830 nm on illumination with near infra red light
- 57. through use ofspecifically designed hd cameras and software system with imposed pseudo color , areas of differential tissue density and vascular supply can be detected clearly with out need of palpation thus facilitating complete resection and clear surgical margins mostly used in minimal access surgeries FIREFLY mode in da Vinci Xi,X robotic surgical systems
- 60. NAVIGATIONAL TECHNIQUES: navigationalbronchoscope to identify , diagnose ,treat small lung nodules creates a 3d road map Head mounted displays
- 62. ERGONOMICS OF LAPROSCOPICSURGERY
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- 64. • ERGON: work •NOMOS: Natural laws or arrangement study of people at work in terms of equipment design,workplace layout,working environment,safety,productivity,training In simple words science of best suiting the worker to his job or to make the setting and surrounding favourable for laproscopic surgeon
- 65. ERGONOMIC CHALLENGES DURINGLAPROSCOPY Lack of tactile sensation : reduces efficacy and increases time of dissection Decreased degree of freedom of movement : 2 dimensional vision with loss of depth perception to some extent, only 4 degree of freedom Tremor enhancement Decoupling of visual and motor axes : -visual orietation changes with loss of depth perception -loss of peripheral binoucular vision caused by limited viewing spectrum offered -have to overcome spatial seperation of axis of vision and axis of physical aspect of the procedure
- 66. Assumption of relativelystatic posture: -surgeon have to be in more static posture leads to build of lactic acid and toxins by muscles and tendons -sensorial ergonomics ( manipulation and visualisation) improves precision , dextrity and confidence - physical ergonomics provide comfort for sugeon More clutter: spaghetti of connections Dark room: risk of choosing wrong instrument
- 67. Factors for idealposture • Height of operating table • Position of visual display • Foot pedal location • Port placement • Related to instrumentation • Surgeon and team position • Technical advancement
- 70. OPERATING TABLE HEIGHT •Ergonomically angle between lower and upper arms hould be between 90 to 120 degrees ( slightly below elbow level) • either lower the table or stand on elevated platform Monitor position: 15 to 40 degrees below the horizontal plane of eye • least neck strain • ceiling mounted monitors, large high definition monitors,monitors with flexible boom,head mounted displays and projection system
- 71. Foot pedal location: -for bipolar device, cautery , ultrasonic shears , other tissue dividing instruments - placed near the foot and aligned in same direction as the instruements towards the quadrants Port placements : - 3 angles MANIPULATION , AZIMUTH , ELEVATION
- 72. • Trocars placedin triangular fashion ( triangulation) in which target organ is 15 to 20 cm from central port ( optical trocar) • 2 remaining trochar in same 15 to 20 cm arc at 5 to 7 cm on either side of optic trochars • Allows instruments to work at 60 to 90 degrees • when optical trocar is placed as one of lateral port trocar : SECTORISATION - done in appendicectomy
- 74. • Manipulation angle: 45 to 75 degrees( between 2 working insruments) • Azimuth angle : 30 to 45 degrees ( between instrument and telescope) • Elevation angle : around 60 degrees( patient body and instrument) • wide manipulation angle necessitate wide elevation angle
- 76. GLASSBOW DIAMOND SUCCESS •A diamond shape anatomical area at umbilicus region that marks the safe zone for veress needle or trocar entry • avoids majot vessels like inferior epigastric arteries and minimizes risk to viscera and bladder • BOUNDARIES: laterally - medial border of both rectus abdominis muscle superiorly-umbilicus inferiorly-pubic symphysis ( or a point midway between umbilicus and pubis) center- linea alba ( avascular midline plane)
- 77. • Factors forsuccess: - proper patient positioning ( trebdelenburg , empty bladder) -lifting abdominal wall while inserting veress needle -using of safety tests -palpation of midline for accurate placement •Significance : safe and effective creation pneumoperitoneum, minimizing complications, commonlyy used with closed or open methods
- 79. RELATED TO INSTRUMENTATION: -limitedview -angulated scopes for better view of anatomy - less efficient instruments ( decreased efficient transmisson of force from surgeons hand to instrument) -limited instrument mobility -instrument exchange during surgery are laborious and distracting to surgeon
- 80. • Health relatedeffects in surgeons : - neck pain , spondylosis - cervical spondylitis , shoulder pain - hand finger joint pains , tenosynovitis,burning eyes
- 83. The cleaner andgentler the act of operation , the less the patient suffers , the smoother and quicker his convalescence , the more exquisite his healed wound - BERKELEY GEORGE ANDREW MOYNIHAN