Safe laparoscopy

Prof. Dr.
Gamal A. M. Antar
Consultant surgeon
F.R.C.S

Advantages of laparoscopy
I. Small Wounds (minimal access)
Less pain.
Less wound infection.
Early ambulation.
Less pulm. compl.
Early resumption of activities.
Better cosmesis.

II Minimal Invasion
Less exposure  less evaporation of body fluids.
Fine manipulations  less tissue damage  less
bleeding and less post op. ileus.
III Better Access and magnification
Oesophageal hiatus, pelvis and porta hepatis.
IV Exploration
Always feasible regardless the type of operation

DISADVANTAGES OF LAPAROSCOPY
I Needs special training
Long special instruments.
Hand – Eye coordination.
II Complicated technology 
Higher failure rates.

III Limited visual field – cameraman.
IV Bidimentional picture (no depth).
V Absent touch and grip.
VI Fixed port sites  fixed angles of work.
VII Difficult control of bleeding:
Absent grip or pack.
Blood on lens.
Blood absorbs light.
VIII Blind steps i.e. veress needle and 1st
trocar.

IX Gas isnufflation under pressure to create a
working space  anaesthetic problems.
X Instruments are difficult to clean, maintain or
sterilize
XI More expensive
XII Time consuming

Complications of laparoscopy
I Due to pneumoperitoneum:
1- Surgical emphysema:
Subcut., scrotal, preperit, retroperit., omental,
mesenteric and mediastinal.
2- Pneumothorax:
Diaphragmatic or pleural injury
Patent pleuroperit. canal.
3- Air embolism
4- Decreased venous return  hypotension + D.V.T.
5- Hypercarbia  arrhythmia and acidosis.
6- Decreased diaphragmatic movements.
7- Spread of malignancy  port metastasis .
8- Spread of infection to surgeon via conjunctiva .

II Visceral injuries (0.16 – 0.27%)
Solid organ or hollow viscus.
Complete or incomplete.
Aetiology:
Lack of relaxation.
Forcible introduction of trocar.
small trocar wound.
Full bladder and distended gut.
Adhesions to abd. wall.
Thermal injuries esp. monopolar.
Faulty techniques i.e. sharp instruments out of field.

Diag:
Asp. from veress needle.
Lap. expln.
May be missed.
Post op. drain.
Treatment:
Prophylaxis.
Early recognition.
Repair (lap. or open).

N.B. Abnormal unexplained bl. or
fluid collection inside the perit. =
??? Injury.

III Vascular injuries (0.64%):
Ant. abd. wall e.g. epig. vs.
Intraabd: liver, omental or mesenteric.
Major vessels: aorta, iliacs or I.V.C.
Aet.:
Lack of relaxtion, small trocar wounds, increased force.
Insufficient pneumoperitoneum.
Blunt trocars.
Bad direction of trocars.
Insufficient exposure of instruments tips.
Abnormal vessels: umb. or urachal.
Diag:
Asp. from veress needle.
Lap. expln.
Via drain.
May be missed:
Retroperit.
Barometric hemostasis.

Treatment:
1- Abd. wall:
- Transillumination.
- Avoid known vessels.
- Diathermy .
- Compression by foley’s balloon.
- Vertical stitches.
2- Intra abd. small vs:
- Clipping.
- Coagulation.
- Gauze compression.
3- Large vs.
- Immediate laparotomy.

N.B. EVERY LAPAROSCOPIC
PROCSDURE SHOULD START & END
BY EXPLORATION.
N.B. Laparotomy Set Should Be Ready In
Every Laparoscopic Procedure.

IV Nerve injuries:
- Common in inguinal and subcostal regions.
- Causalgia, hyposthesia or neuroma.
- Avoided by adequate knowledge of anatomy. e.g. no
stappling of mesh below level of int. ring in
herniorrhaphy.

Thermal injuries:
-Revealed 4-10 d. post op.
-Related to instrument used and surgeon’s
experience.
Monopolar diathermy:
-Pt. is a part of the electric circuit.
-Current passes in the direction of least
resistance  may affect untargetted tissues
specially if large grip of tissues.
-High heat radiation.
Electric spark  furthur injury.

Bipolar diath:
-Pt. is not a part of the circuit.
-New instruments include scissors and hooks.
-High heat radiation.
Laser:
-Expensive.
-Needs special experience.
-Minimal tissue damage.

Argon beam coagulator:
-Spray surface coagulation e.g. suitable for G.B.
bed.
-Minimal penetration.
-Expensive.
-May increase. I.A. pressure.
Endo coagulator:
-Very slow.
-Very safe.
-Minimal damage.
Ultrasonic coagulation:
-No electric current.
-No smoke.
-Minimal tissue destruction.
-Expensive.
-Slower than electrocag.

LIGASURE
- Radiofrequency sealing energy + cutting
- Can seal vessels upto 7 mm.
- Computer feed back
- Minimal lateral damage

HOW TO AVOID THERMAL INJURIES :
1.Choose the most suitable tool for the procedure
2.Use the least possible coagulation power.
3.Cauterize the least amount of tissues at a time.
4.The whole uninsulated shaft of inst. should be under
vision.
5.Multiple short repeated shots are better than a long one.
6.Foot switch should be controlled by surgeon HIMSELF.
7.Proper connection & insulation of patient.

LATE COMPLICATIONS OF LAPAROSCOPY:
1- Port site infection: depends on the procedure:
0.1% in diagnostic lap.
0.25 – 1% in lap. chole.
2-3% in lap. appendectomy.
Can be reduced by retrieval bags.
2- Port site hernia: 0.1 – 0.3%:
More with sharp trocars and big incisions i.e.
> 10 mm.
Avoided by closure of trocar sites 10 mm or more
e.g by Maciol needles.
3- Int. obst:
Adhesive: less than in open surgery.
Incarceration in port hernia e.g. Richter’s type.
4- Ascitic fluid leak in liver C. and esp. if a drain is left.

Proper training programs:
-Theoretical knowledge about laparoscopy, instruments
used, their mode of work & their problems. This should
include technicians & nurses.
-Re orientation about the anatomy seen from a different
angle.
-Aquaintance about practical handling of new instruments.
-Hand eye coordination with the help of pelvitrainers.
-The use of simulators e.g. G.B., appendix, models for
intracorporeal stitching and knotting.
-Full operations on animal models e.g pigs.
-Operating on human patients under strict supervision.
-Continuous training for advanced and new techniques.

Improvement of vision:
-Checking equipments before start.
-Checking connections e.g. a drop of cidex or saline bet. scope
and camera or light cable can lead to failure of procedure.
-Proper placement of scope (not necessarily at the umb.).
-Minimize gas leak.
-The use of 3 chip camera improves colours definition.
-The use of 3D camera with special glasses improves the depth
of picture.
-Higher resolution of camera and monitor improve quality of
picture.
-Thermoflators and antifog soln. can reduce fogging on scope.
-Trained understanding camera man in a team is a must.
-Select the topography of ports to achieve the best angles of
work.
- The use of angled scopes can be of help in special situations.

How to avoid needle & trocar injuries:
1-Adequate relaxation.
2-Proper choice of site of 1st
entry.
3-Lift abd. wall up when introducing veress or blind trocar.
4-Direction towards pelvis or Lt. HC.
5-Evacuate bladder , use NGT before opn.
6-Do abd. US before opn.
7-Do not use blunt tocars.
8-Safety shield trocars are preferred.
9-The use of VISIPORT to penetrate under vision can help.
10-Open laparoscopy should be an alternative esp. if previous
laparotomy or distended gut.
11-Force should come from wrist not from shoulder i.e. avoid
excess force.
12-Always test veress needle by asp. + drop test.

GENERAL TIPS:
•The use of intra operative lap. Us probes can help
differentiate vessels and ducts.
•The use of intraop. endoscopy upper or lower can also
add to the safety e.g in achalasia of cardia, H.H or
gastroplasty.
•Reusable instruments are better if autoclavable.
Ethylene Oxide gas is an alternative though expensive
.Cidex steilization is better avoided but if recessary it
should be fresh and has sufficient time to work.
•Disposable instruments should not be reused.
•Patients should be fully monitored during operation
and if necessary procedure should be turned into an
open surgery-
* LAPAROLIFT (gasless laparoscopy ) can be an
alternative to gas insufflation esp. in cardiac pts. or in
those with history of D.V.T. , ALSO HAND ASSISSTED
TECHNIQUES CAN BE OF HELP .

SAFETY MEANS
- PROPER TRAINING PROGRAMS.
- PROPER PT. MONITORING THROUGHOUT THE
WHOLE PROCEDURE.
- PROPER STERILIZATION OF EQUIPMENTS &
INSTRUMENTS.
- ACHIEVEMENT OF BEST POSSIBLE PICTURE,
FIELD & VISION.
- AVOIDANCE OF ANY BLIND STEP.
- CONVERSION INTO AN OPEN SURGERY IS NOT
A FAILURE.

Safe laparoscopy

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Safe laparoscopy