Diagnostic Laparoscopy

Diagnostic laparoscopy, also known as keyhole surgery

1. Diagnostic Laparoscopy: (keyhole surgery)

2. OUTLINE: What is laparoscopy? Minimally invasive surgery? Indications? Advantages? Disadvantages? Steps involved? Pre-theatre prep Positioning & theatre set-up Surgery step(s) Complications? WinnerzKlub Authentic 20

3. What is laparoscopy? Is a type of surgical procedure classified as a “minimally invasive” procedure. Procedure allows surgeon to gain access to the peritoneal cavity, without having to make large incisions. Differs from an “open” surgery where incision on skin can be several inches long. Procedure takes its name from the laparoscope – the main instrument used in this procedure. Laparoscope is a slender, tall metal instrument that has both video camera & light source on its end which allows surgeon to “see” the interior of the abdomen. WinnerzKlub Authentic 20

4. Minimally invasive surgery: The core principles of minimally invasive surgery (independent of procedure or device): Insufflate/create space – to allow surgery to take place in the minimal access setting. Visualize – the tissues, anatomical landmarks & the environment for the surgery to take place. Identify – the specific structures for surgery. Triangulate – surgical tools (such as port placement) to optimize the efficiency of their action, & ergonomics by minimizing overlap & clashing of instruments. Retract - & manipulate local tissues to improve access & gain entry to the correct tissue planes. Operate – incise, suture, anastomose, fuse. Seal/hemostasis . WinnerzKlub Authentic 20

5. Minimally invasive surgery: Advantages: Decrease in wound size. Decrease in wound pain. Improved mobility. Reduction in wound infection, dehiscence, bleeding, herniation & nerve entrapment. Decreased wound trauma. Decreased heat loss. Improved visualization. Limitations: Reliance on remote vision & operating. Difficulty with haemostasis. Dependence on hand-eye coordination. Extraction of large specimens. Reliance on new techniques . WinnerzKlub Authentic 20

6. Laparoscopy: WinnerzKlub Authentic 20

7. Indications: Laparoscopy can be used to assist in diagnosing a wide range of conditions that develop in peritoneal cavity. In fact, it can also be used for therapeutic purposes (surgical procedures) such as removing a damaged or diseased organ/tissue, or obtaining a sample for further testing. Acute/emergency: Upper abdominal pain with suspected perforated peptic ulcer. Lower abdominal pain with suspected acute appendicitis. Elective: Investigation of chronic abdominal pain. Investigation of subfertility. To perform BIOPSY (e.g. omental or lymph node). WinnerzKlub Authentic 20

8. Advantages: Compared with traditional “open” surgery: Less severe post-operative pain. Reduced hospital stay (postoperative). Earlier return to normal activities. Less internal scarring Smaller scars WinnerzKlub Authentic 20

9. Disadvantages: Takes longer to perform than “open” surgery (if not performed with right technique). Longer time under anaesthesia increases risk of complications, which may occur few days to few weeks after surgery. Possibility of Hernia (incisional) Internal bleeding Damage to blood vessels & other organs, such as stomach, bowel, bladder or ureters. WinnerzKlub Authentic 20

10. Pre-theatre prep: Always done under GA; therefore NBM 2h & fluids only 4h preop. Group and save required. Ensure consent is obtained for proceeding to other procedures if they are anticipated. WinnerzKlub Authentic 20

11. Theatre set-up: Urethral catheterization : Usual, especially if lower abdominal pathology/assessment likely, to ensure the bladder is decompressed. NGT : NOT required unless the patient is vomiting or gastric distension/surgery is likely. Table positioning : Supine . It is always best to have the patient in leg extensions. They allow the perineum to be assessed if vaginal manipulation or lower GI endoscopy is needed and they help to secure the patient on the table if head downtilt or lateral role is required. Monitor/stack position : Depends on the expected pathology. WinnerzKlub Authentic 20

12. Surgery Steps: Incision : Periumbilical; usually curved infra-umbilical although supra-umbilical is also used. Vertical infra-umbilical can be used, especially where conversion to a midline laparotomy is anticipated. Exposure of the linea alba : By sharp dissection. Incision of linea alba : Elevate with forceps & incision with scalpel. Open trochar insertion : Elevate linea alba with forceps, blunt scissor opening of pre-umbilical fat pad & peritoneum and placement of trochar or: Blunt trochar insertion: Elevate linea alba with forceps without a small initial incision, insert trochar (blunt or with visual assistance using laparoscope inside the port) or: Verres needle insertion : Elevate linea alba with forceps, insert Verres needle using only thumb and finger pressure, until ‘clink’ felt, test for intraperitoneal placement with saline ‘drop’ test. Insufflation: Use slow flow initially, check for slow pressure flow before increasing flow rate. Assessment: Inspect area beneath insertion port for signs of visceral injury or bleeding, assess anterior abdominal wall for availability of further port sites, inspect viscera sequentially. WinnerzKlub Authentic 20

13. Post-operative care: Remove catheter unless required for post-operative fluid balance observation. Antibiotics: Only required if pathology found. Oral diet: Normal as soon as tolerated. WinnerzKlub Authentic 20

14. Complications: Port site infection (<5%) Port site herniation (<2% if closed). Visceral injury during port insertion/basic laparoscopy & assessment (<1%). WinnerzKlub Authentic 20

15. The End References: Oxford Handbook of Clinical Surgery, 4 th Ed. Bailey and Loves, Short Practice of Surgery. WinnerzKlub Authentic 20