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Principle of laparoscopic surgery
- 1. Principles of Laparoscopicsurgery Presenter : Dr. Annush Tha Moderator: Dr. DA/DB Department of Surgery Pokhara Academy of Health Sciences 2077-08-07
- 2. Principles of Laparoscopicsurgery
- 3. Learning objectives • Introduction •Principles of laparoscopic surgery • Advantages and disadvantages • Safety issues • Principles of postoperative care • Recent advances in modern surgical practice
- 4. Minimally invasive surgery(MIS) •Means of performing major operations through small incisions using miniaturized, high tech imaging systems to minimize the trauma of surgical exposure • Coined by John Wickham • Also known as laproscopic surgery or Minimal access surgery
- 5. Historical background • 19011st experimental laparoscopy procedure done by Georg Kelling termed “celioscopy “—examined abdominal cavity in dogs using cystoscope • Hans Christian Jacobaeus successfully applied minimal invasive techniques in human • Coined the term “laparoscopie” and “Thoracoscopie” • Bertram Berheim from John Hopkins first performed laparoscopy in United States • Patrick Steptoe applied this approach in 1980 in UK • Philipe Mouret’s First video laparoscopic cholecystectomy ,Lyon- 1987
- 6. Core principle ofMIS • (I-VITROS) I - insufflate/create space V- visualize-( anatomical landmark, tissue ,surgical environment) I - identify-( specific structures for surgery) T- triangulate(surgical tools to optimize efficiency, ergonomics, minimize crowding/clashing) R – retract ( manipulate and access the correct tissue plane) O- operate (incise, suture, anastomose) S – seal/Hemostasis
- 7. Advantages of minimalaccess surgery Decrease wound size Reduction in wound infection , dehiscence , bleeding , herniation and nerve entrapment Decrease wound pain Improved mobility Decreased wound trauma Decreased heat loss Improved visualisation
- 8. Limitations Reliance on remotevision and operating Dependence on hand eye coordination Difficult with hemostasis Reliance on new technique Extraction of large specimens Loss of tactile feedback Expertise and training required
- 9. MIS categories • Laparoscopy •Thoracoscopy • Endoluminal endoscopy—urology, git, respiratory and vascular systems • Perivisceral endoscopy- mediastinoscopy, retroperitoneoscopy, etc • Arthoroscopy and intra-articular joint surgery • Spectrum – Diagnostic/Therapeutic
- 10. Preparation for laparoscopicsurgery • Overall fitness of the patient: History and examination • Previous surgery- scars, adhesions • Body habitus: obesity, skeletal deformity • Coagulation profile and thrombocytopenia • Informed consent
- 11. Prerequisites for MIS •Equipment and OR setup • Technique • Training
- 13. General intraoperative principles •Patient positioning depending upon the surgical procedure • Creating pneumoperitoneum Closed method Open method • Physiologic effects of CO2 pneumoperitoneum • Gas specific effects • Pressure specific effects
- 14. Closed method • Involvesblind puncture using Verres needle • Fast and relatively safe • Potential risk for intestinal or vascular injury on introduction of the needle or first trocar • Check verres needle for spring action and patency with NS
- 15. • 1 cmhorizontal or vertical incision at level of umbilicus • Abdominal wall on both side grasped with finger/allis forcep and raised • Verres needle introduced at angle of 45° directing towards the pelvis or anus(or perpendicular to the abdominal wall) • Popping sensation felt on piercing through linea alba and peritoneum • Do irrigation test aspiration test hanging drop test with NS(lift abdominal wall NS sucked in) • Insufflate with CO2 gas up to maximum pressure 14-15mm of Hg • Remove Verres needle and introduce 5-10 mm trocar
- 16. Open method/ Hassonmethod • Definite and small risk of bowel injury • Increasing number of surgeons performing laparoscopy without experience • Useful in patients with abdominal surgery or underlying adhesions
- 17. Open / Hassonmethod • 1cm vertical or transverse incision made at level of umbilicus(above or below) • Retract and Blunt dissection to expose midline fascia • Two sutures inserted on either side of midline incision and 1cm opening created in fascia • Peritoneum identified and opened • Finger introduced to verify free access to abdominal cavity (R/O bowel adhesion) • Hasson trocar introduced and held with stay sutures at its wings • Insufflation with CO2
- 18. Port placement • Trocarsfor surgeons left and right hand placed at least 10 cm apart • Ideal trocar orientation creates equilateral triangle between surgeons right hand, left hand and the telescope(Baseball Diamond configuration) • Surgeon stands behind the telescope • Inability to space trocars severely limits the ability to triangulate the left and right hand instruments
- 19. Preoperative problems • Previousabdominal surgery • Not a contraindication • assesse the type and location of scars • Open method for pneumoperitoneum • Laparoscope used to as blunt dissector to traverse through adhesions • By careful pushing and twisting motion under direct vision
- 20. • Obesity • Technicallydifficult on • creating pneumoperitoneum—(coz of increased thickness of subcutaneous fat) • accessing operative region and • achieving good exposure in presence of an obese colon • Overcome difficulties by: • Use supra umblical incision large 1-3cm • Direct verres needle at right angle to skin(if closed method used) • Hasson method preferred • Use larger and longer instruments to reach operative site
- 21. Operative problems • Intraoperativeperforation of viscus • Bowel, solid organs and blood vessels • Best is to avoid with utmost care and precision • Antibiotics • Prophlaxis with in 1 hour of skin incision • Established sepsis or septicemia not recommend for MIS except for removing foci of infection
- 22. • Bleeding • Mostcommon cause to conversion to open surgery • Limits the field of operation • Obscures the operative field • Magnification confuses small arterial bleed as the significant hemorrhage • Light absorption obscures the visual field 1. Bleeding from major vessel Identify bleeder and achieve hemostasis with electrosurgery(diathermy) Good suction and irrigation well managed Use surgical if required Consider open procedure without delay if bleeding couldn’t be controlled
- 23. 2. Bleeding fromorgan • Can be prevented if dissection is done in correct plane • If bleeding from organ is noted dissection is extended to locate the bleeding point electrocautery hemostasis • Bleeding persists bleeding point grasped with insulated grasper electrocautery applied to grasper to achieve the hemostasis
- 24. • 3. Bleedingfrom trocar site • Controlled by applying upwards and lateral pressure with trocar • Occurs if falciform ligament is pierced with substernal trocar or epigastric vessels are injured • Monofilament suture attached to specialized needle passed into abdominal cavity and exited at other side of ligament using grasper • Loop suspended and compression achieved during procedure hemostasis remove loop after procedure under direct vision ensure hemostasis • If significant bleeding occurs apply pressure or suture • Pressure applied with foleys catheter entered into trocar site inflate balloon maintain in traction keep for 24 hours and remove
- 25. Post operative care •Most common post op complains are Nausea Managed with antiemetics Controlled within 12-24 hours Avoid opiate analgesics Shoulder tip pain Referred from diaphragm, worst at 24hour after operation Settles within 2-3 days and controlled with paracetamol
- 26. Abdominal pain Port sitepain present but worse if hematoma formation occurs Increasing pain after 2-3 days suspect infection and run tests and treat appropriately with antibiotics Herniation through port site may produce localized pain If increasing pain, tachycardia or pyrexia review the case and relaparoscopy should be considered Oral fluids and food Started after 4-6hours post op except in colectomy or small bowel resection Light meal can be given
- 27. Catheter anddrain Foleys if applied remove after procedure Drain applied to assess Post operative blood loss Nature of intraperitoneal fluid Postoperative monitoring needs Drain if placed to vent gas and peritoneal fluid remove with in 1 hour after operation If placed for hepatic bleeding or bile leakage remove when drain has achieved its function (after 12-24 hours) If continued blood loss from drain re explore the abdomen
- 28. Special consideration • Pediatriclaparoscopy • Laparaoscopy in infant and child requires specialized instruments • Instruments are shorter (15-20cm )and 3mm in diameter( 5mm in adult) • 5mm telescope (adult 10mm) • Abdominal wall thinner– • pneumoperitoneum 0.1L/min/Year(flow rate) up to 10 year • 1L/min adult and 10yr after wards • Pneumoperitoneum pressure 8mm of HG • Used for colonic aganglionosis( pull through procedure) , congenital diaphragmatic hernia repair, etc
- 29. • During pregnancy •Access to abdomen based on the height of uterine fundus which reaches the umbilicus at 20wks • Timing of operation- 2nd Trimester if possible • Position –slight left lateral to avoid venacava compression • Use Sequential compression device in all cases ( to avoid thromboembolism) • Use Hassons technique for pneumoperitoneum • Avoid maternal acidosis to prevent fetal acidosis( avoid hypercarbia) • Consider open procedures if fetal distress expected after pneumoperitoneum
- 30. • Laparoscopy inelderly and infirm • Older patients more likely to require conversion to celiotomy( open surgery) • Requires close monitoring of anesthesia • Intraoperative management more difficult in laparoscopic > open surgery • MIS improves mobility after surgery so reduces morbidity which are result of reduced mobility in elderly
- 31. Advances • Robotic surgery •Robot performs automated physical tasks according to direct human supervision, predefined program or set of guidelines using AI • Assists the surgeon during procedure
- 32. • Two categoriesexist: • 1. Teleopreated system: • Human surgeon performs the operation via a robot and its robotic instruments through televisual computerized platform either via onsite connections or remotely through internet • 2. Image guided system • Surgical robot completes a pre programmed surgical task which is guided by preoperative imaging and real-time anatomical constrains • Follows inbuilt navigation system
- 33. Single incision LaparoscopicSurgery(SILS) • All instruments inserted via single incision through multiple channel port via umbilicus to carry out procedure • Benefit : • Single opening via umbilicus– scarless • Fewer ports so less pain, less risk of bleeding and reduced incidence o port site hernia
- 34. NOTES( Natural orificetranslumenal endoscopic surgery) • Entry into the peritoneal cavity via endoscopic puncture of a hollow viscus which is carried out via natural orifices • Transvaginal , transvesiccle, transanal, transcolonic, transgastric and transoral approaches • The ease of decontamination entry and closure of structures create a challenge • Extraction GB,kidney, appendix, bladder, etc done via transvaginal route
- 35. Take home message •MIS has advantages over the open procedure in terms scar, post operative pain and early return to work • Requires sophisticated instruments and ample experience to perform the procedure correctly and safely • Advances like SILS, Robotic surgery, NOTES are underway
- 36. References • Bailey andlove’s Short practice of Surgery-27th Edition • Schwartzs principles of Surgery -10th Edition
- 37.