Concept laparoscopic surgery

basics of minimal access surgery/ laparoscopic surgery

1. Concept of Laparoscopic Surgery

2. Learning objectives Terminologies Laparoscopy Various methods Advantages Limitations Pre-requisite- workup, setup & tools General principles

3. Terminologies Minimal Access Surgery(MAS) surgical innovation that aims to accomplish surgical therapeutic goals with minimal somatic and psychological trauma . reduced wound access trauma, as well less disfiguring than conventional techniques Minimal Invasive Surgery(MIS)

4. Laparoscopy: History First laparoscopic cholecystectomy – done by Muhe of Germany in 1985 & by Mouret in Lyon in 1987 in USA in 1988, by McKeran and Saye In India, by Professor TE Udwadia First laparoscopic appendicectomy – done by Semm as prophylaxis by Schreiber in 1987 for acute appendicitis

5. Laparoscopy: Advantages Relatively less painful Trauma of access is very less Shorter hospital stay and early return to work Faster postoperative recovery Better visualization of the anatomy, better approach for dissection and visualization of other parts of abdomen for any other pathology Instrumental access to different locations is many times better Minimal scar

6. Laparoscopy: Limitations Relative contraindications: Compromised cardiac status Peritonitis Previous abdominal surgeries. Bleeding disorders. Morbid obesity. Third trimester pregnancy. Portal hypertension.

7. Laparoscopy: Limitations.. Limitations of MIS: Reliance on remote vision and operating Loss of tactile feedback Dependence on hand–eye coordination Difficulty with haemostasis Reliance on new techniques Extraction of large specimens

8. Laparoscopy: Prerequisites Overall fitness: cardiac arrhythmia, emphysema, medications, allergies Previous surgery: scars, adhesions Body habitus: obesity, skeletal deformity Normal coagulation Thromboprophylaxis Informed consent Instruments used

9. Laparoscopy: Prerequisites.. Instruments used: Laparoscope Camera Cold light source Video monitor C02 insufflator Surgical instruments: Long fine dissectors Hooks & spatulas Clip applicators Needle holders Endostaplers Veress needle Suction-irrigation apparatus Trocars Reducers

10. Laparoscopy: Prerequisites.. Preparation: General anesthesia Prevention of inadvertent injuries Pressure bandages/ cuffs Position of patient Strapping According to surgery Reverse trendelenberg position

11. Laparoscopy: Technique Access: Open vs. closed method Creation of pneumoperitonium Visualisation Additional ports Triangulation Ergonomics Sometimes additional incision required

12. Laparoscopy: Physiologic changes CO2 causes hypercarbia , acidosis and hypoxia. Pneumoperitoneum decreases the venous return increases the arterial pressure It compromises the respiratory function by compressing over the diaphragm

13. Laparoscopy: Complications CO2 narcosis and hypoxia Sepsis- subphrenic abscess, pelvic abscess, septicaemia. IVC compression . Bleeding. Leak from the site, e.g. bile leak. Organ injury during insertion of ports. Subcutaneous emphysema and pneumomediastinum .

14. Laparoscopy: Complications.. Gas emboli, though is rare but fatal. Postoperative shoulder pain due to irritation of diaphragm. Cardiac dysfunction due to decreased venous return. Injury to the abdominal wall vessels and nerves . Cautery burn to abdominal structures. Abdominal wall hernias. Wound infection. Mortality-0.5%.

15. Laparoscopy: G eneral principles Core principles of MAS summarized by acronym I VITROS Insufflate/create space Visualise – the tissues, anatomical landmarks and the environment for the surgery to take place Identify Triangulate – surgical tools (such as port placement) to optimise the efficiency of their action, and ergonomics by minimising overlap and clashing of instruments Retract – and manipulate local tissues to improve access and gain entry into the correct tissue planes Operate – incise, suture, anastomose, fuse Seal/ haemostasis .

16. Laparoscopy: Procedures Basic surgeries: Laparoscopic cholecystectomy. Laparoscopic appendicectomy . Advanced surgeries: Hernia repairs, splenectomy , fundoplication, vagotomy & GJ, Colectomy: APR, LAR, hysterectomy, urologic procedures, thoracic/thyroid/ paediatric surgeries etc.

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