BASIC LAPAROSCOPY BY DR Mena Zarif Lecturer of
BASIC LAPAROSCOPY BY DR/ Mena Zarif Lecturer of general and laparoscopic surgery Faculty of Medicine Sohag university
The first description dates to Hippocrates in Greece, for use of a speculum to visualize the rectum (460– 375 BC). A three bladed speculum was found in the ruins of Pompeii*. *A roman town buried by a volcano eruption near modern Naples, Italy - 79 AD).
1910: Swedish internist; first thoracoscopic diagnosis with a cystoscope in a human subject. Treatment of a patient with tubercular intra-thoracic adhesions. The Possibilities for Performing Cystoscopy in Examinations of Serous Cavities. Münchner Medizinischen Wochenschrift, 1911
1911 : First laparoscopy at Johns Hopkins 12 mm proctoscope into epigastric incision on one of Halstead’s patients to stage pancreatic cancer Bernheim called his procedure ‘organoscopy’ Findings confirmed on laparotomy
1985: Dr. Muhe (Prof Dr Med - Böblingen, Germany) performed the first successful laparoscopic cholecystectomy in a human. However, this was not well publicized until years later. The German Surgical Society rejected Mühe in 1986 after he reported that he had performed the first laparoscopic cholecystectomy.
Minimal access surgery is a marriage of modern technology and surgical innovation that aims to accomplish surgical therapeutic goals with minimal somatic and psychological trauma
Laparoscopy Thoracoscopy Endoluminal endoscopy Arthroscopy
DIAGNOSIS Gallstone Appendicitis Hernia Adhesions Perforated ulcer Hiatus Hernia OPERATION Cholecystectomy Appendicectomy Hernia repair Division of adhesions Closure of perforation Hiatus hernia repair.
DIAGNOSIS Colorectal carcinoma Caecal carcinoma OPERATION Anterior resection/ APR Right Hemicolectomy Colonic carcinoma Gastric carcinoma Oesophageal carcinoma Left/Sigmoid Colectomy Gastrectomy Oesophagogastrectomy
Diagnosis Crohn’s Disease Diverticulitis Rectal Prolapse Benign renal disease Gastric Obstruction Some Splenic disorders The list is endless!!! Operation Bowel resection Repair of Prolapse Nephrectomy Bypass Spleenectomy
FOR THE Patients Post operative pain related to size of incision- smaller incisions =less pain. Less Handling of intestines results in little or no disturbance of normal function.
FOR THE HOSPITAL Reduced overall costs by shortening of hospital stay e. g. cholecystectomy reduced from 5 to 1 day, hiatus hernia repair reduced from 7 to 3 days.
Absolute : Uncorrectable coagulopathy Frozen abdomen Sever cardiac dysfunction (grade Iv) Failure to tolerate general anesthesia Uncontrolled shock
Relative : Multiple abdominal adhesions Abdominal peritonitis
Camera Light Source Insufflator TV Monitor Telescopes Light Guide Cable
These can be single chip or 3 chip(red, green, blue). CHIP: this is also called a charged coupled device in short, CCD. These are flat silicone wafers with a matrix, a grid of minute image sensors called pixels. White balance and sometimes black balance
Halogen or Xenon, cold light. Brightest to darkest measured in units of decibels. White balance by making sure white is correct then all the colours through the spectrum are correct.
CO 2 is used because this has the same refractive index as air, so doesn’t distort the image and is non combustible. Intraabdominal pressure run between 10 and 13 mmhg. Use disposable filter and tubing for each patient. High flow insufflators (35 litres) output determined by size of outlet. Ensure you know how to change a cylinder and were they are stored.
Usually a 20” screen. HD is better. You can use a standard TV but it must be run through an isolated transformer. Horizontal resolution is the number of vertical lines. Vertical resolution is the number of horizontal lines More lines of resolution, better detail of picture.
Different diameters Fibre light cable Autoclavable Don’t bend to acute angle as will break fibres. Check when you plug them in are all the fibres are okay. Condensers
Single use Reusable
n 1938 - Janos Veress, of Hungary, developed the spring-loaded needle. to perform therapeutic pneumothorax (TB). n Made of surgical stainless steel with a single trap valve. 2 mm diameter x 80 mm length n It consists of an outer cannula with a bevelled needle point for cutting through tissues.
ABDOMINAL ACCESS INSTRUMENTS Open Technique Closed Technique Hasson Cannula Veress Needle Trocar Sheath assemblies
n The trocar has a blade with a shaft and body. The body includes a pointed tip which makes the initial incision in the abdominal wall of the patient. (Trocar diameters range from 2 mm-30 mm) n
n Types: n Cutting n Pyramidal tipped n Flat blade n Noncutting n Pointed conical n Blunt conical n Optical
n Atraumatic n KELLY atraumatic n Atraumatic, with hollow jaws n MANGESHKAR Grasping Forceps, serrated
COMPLICATIONS OF LAPAROSCOPIC SURGERIES 1. Anaesthetics Complications 2. Complications due to pneumoperitonium 3. Surgical complications 4. Diathermy related injuries 5. Patients factors related complications 6. Post operative complications
COMPLICATIONS DUE TO PNEUMOPERITONIUM CO 2 pneumoperitonium (a) Gas specific effects (b) Pressure Specific Effects 1. Respiratory Acidosis 2. Hypercarbia Reduced VR Excessive Pressure on IVC Reduced CO Management - • Desufflation of abd. membrane Rapid stretch of peritoneal • Vagolytic (Atropine) Vasovagal response • Adequate volume replacement hypotension Bradycardia, occasionally
Pneumothorax • Due to true diaphragmatic hernia. • Without any apparent cause. Diagnosis • Presence of rapidly falling Oxygen saturation or PO 2 together with difficult ventilation and decreased breath sounds. Management – • Immediate needle thoracostomy. • Aspiration • Chest radiograph • Placement of chest tube
Subcutaneous and Subfascial Emphysema and Edema Improper insertion of veress needle Manipulation of instruments often loosens the parietal peritoneum surrounding the instruments portal of exit into the peritoneal cavity. CO 2 then infiltrates the loose areolar tissue of the body Subcutaneous and sub fascial emphysema * It rapidly resolves within 2 – 4 hours postoperatively.
SURGICAL COMPLICATIONS -Visceral injuries -Vascular injures
Vessel Injury : • Larger vessels may be injured by trocar or veress needle. • CO 2 peritoneum may tamponade a large vessel injury. • When pressure normalizes it starts bleeding. Management – • Examine the course of large vessels. • Overlying peritoneum is opened with laproscopic scissors or a CO 2 laser. Hematoma evacuated by alternate suction and irrigation. * Laprotomy is required if hematoma is expanding or persistent bleeding.
Vessel Injury : Epigastric Vessels – • Deep epigastric vessels most frequently injured in laproscopic hysterectomy. Management – By Tamponade – • By Foley’s catheter • Bipolar coutery • Needle suturing • Small haemostat (Mosquito clamp) Ovarian or uterine vessels – • Injured during laproscopic hysterectomy Management – • Bipolar desiccation • Ureter must be identified before desiccation.
DIATHERMY RELATED INJURIES Due to – • Inadvertent activation of the diathermy pedal. • Faulty insulation Cautery should be used under vision Injuries – • Thermal necrosis of organs. • Inadvertent organ ligation. • Unrecognized haemorrhage.
POST OPERATIVE COMPLICATIONS • Concealed injury to organs • Delayed feacal fistula • Port site metastasis • Residual air (Referred chest or shoulder pain)
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