LAPAROSCOPIC CHOLECYSTECTOMY( SURGERY).pptx

A useful and informative presentation pn lap cholecystectomy

1. LAPAROSCOPIC CHOLECYSTECTOMY PRESENTED BY:  FAKHARA KHAN PG SCHOLAR ,D/O JARAHAT AMU

2. INTRODUCTION

3. CONTRAINDICATIONS

4. EQUIPMENTS   Laparoscopic monitor One laparoscope (5/10 mm, 0/30 degrees) including camera cord and light source Carbon dioxide source and tubing for insufflation 5 mm to 12mm trocars (average three 5 mm working trocars and one 10 mm to 12 mm trocar) Laparoscopic instruments: Atraumatic graspers, Maryland grasper, clip applier, electrocautery (e.g., hook, spatula), and a retrieval bag/ forcep Scalpel (11/15 blade), forceps, needle holder, and absorbable sutures Major open tray, for possible conversion

5. LAPAROSCOPE: It is a telescope its diameter varies from 1.9mm to 10mm  Commonly used is a 0 degree angle telescope but 30 degree can be rotated slowely can see down into grooves and gutters and can look up the anterior abdominal wall and sideways.

6. INSUFFLATOR: Surgical insufflation safely transports CO2 to the patient's body, most commonly the abdomen, to distend the working area and allow better access to anatomy and use of surgical tools.

7. TROCAR: Trocar is a laparoscopic device that is made up of an obturator (which may be a metal or plastic sharpened or non-bladed tip) and a cannula (basically a hollow tube). Trocars are placed through the abdomen during laparoscopic surgery. The trocar functions as a portal for the subsequent placement of other instruments, such as graspers, scissors, staplers, etc

8. Trocar with obturator 10mm and 5mm trocar

9. VERESS NEEDLE: It is used to create pneumoperitoneum It is spring loaded to prevent visceral injury  Once peritoneal cavity is entered blunt tip projects out

10. MARYLAND DISSECTOR: Maryland dissector instrument is inserted through 5 mm/10mm trocar. Dissector comes with long, curved jaws and fine-tapered tips Dissectors used mainly for separation of sac from cord structures Rotating shaft for allowing easy dissection with lesser strain to surgeon's wrist Sharp and insulated scissor finish As a monopolar electrosurgical instrument it finds use for dissection and hemostasis using flexible endoscopes with working channel

11. CLIP APPLICATOR: This is used to ligate the vessels and ducts. The applicator is first loaded with metallic clip and then clip is applied by applying pressure to handle of the instrument.

12. POSITION OF SURGICAL TEAM: The surgeon stands on the left side of the patient with the These scrub nurse-camera holder-assistant. One assistant stands ones. right to the patient and should hold the fundus-grasping forceps.

13. PATIENTS POSITION: Patient is operated under General anesthesia in the supine position with a steep head-up and left tilt.  This typical positioning of laparoscopic cholecystectomy should be achieved once the pneumoperitoneum has been established.  The patient is then placed in reverse Trendelenburg's position and rotated to the left to give maximal exposure to the right upper quadrant.

14. PORT PLACEMENT: Primary: Umbilicus- 10mm port- laparoscopic telescope 30* angled Secondary:- Epigastric- 5mm or 10 mm-working port operating port :Rt subcostal medial- 5mm port:  Rt subcostal lateral- 5mmport- static retractor  Introduce secondary trocars under laparoscopic vision

15. LAPARASCOPIC ANATOMY OF GALL BLADDER: Laparoscopic view of the right upper quadrant on first look or duodenum will demonstrate primarily the subphrenic spaces, abdominal surface of diaphragm, and diaphragmatic surface of the liver. Exposure of the fundus of the gallbladder can be seen popping from the inferior surface of liver  the falciform ligament is seen as prominent dividing point between left subphrenic space and the right subphrenic space. As the gallbladder is elevated and retracted towards the diaphagram;adhesion to omentum or duodenum or transverse colon is seen.

16. STEPS: P repration of the patient Creation of pneumoperitoneum Insertion of ports Dissection of calots triangle Clipping and division of Cystic Duct and artery Dissection of Gall bladder from  liver bed Extraction of Gall bladder and any spilled stone Irrigation and suction of Operating field  Removal of the instrument with complete exit of CO2 Closure of wound

17. EXPOSURE OF HILUM The gallbladder fundus is secured with 5mm ratchet grasping forcep from anterior axillary port. Traction of fundus of gall bladder shifts the right lobe of liver in cephalad manner which gives adequate exposure of calots triangle and hilum of the liver

18. ADHESIONS RELEASE: Adhesions to the inferior surface of the liver and gall bladder are carefully taken down beginning near the fundus and proceeding down towards the neck . Retract the adhesions towards the bottom with left hand grasper. Adhesion may contain omentum,colon,stomach and hence they must be dissected with care.

19. PRELIMINARY DECOMPRESSION: If the GB is acutely inflamed and tensed decompression is done: 1: Percutaneous Veress neddle aspiration 2: Introduce the 5mm trocar in the fundus of GB directly and aspirate the infected fluid by suction. By repeated instillation of saline and aspiration ,whole infected contents may be removed.

20. Dissection of Cystic Pedicle

21. Sepration of Cystic Duct from the Artery: Once the cystic duct is visualized, the dissector can be used to create a window in the triangle of Calot between the cystic duct and cystic artery. This window should be created high near the gallbladder-cystic duct junction to avoid injury to the common duct.

22. CONT.. The separation of the cystic duct anteriorly from the cystic artery behind can be performed by a Maryland's grasper by gently opening the jaw of Maryland between the duct and  artery. The opening of the jaw of Maryland dissector should be in the line of duct never at right angle to avoid injury of the artery behind. Sufficient length of the cystic duct and artery  on the gallbladder side should be mobilized so that three clips can be applied. The cystic artery is clipped and divided, two clips are placed proximally on the cystic artery and one clip is applied distally the artery is then grasped with grasper on GB wall then divided.

23. Division of cystic duct and Artery: The cystic artery is clipped and then divided,two clips are placed proximally on the cystic artery and one clip is applied distally . After isolating the cystic duct and artery the clipper is introduced through the epigastric  port and atleast two clips are placed on the proximal side of cystic duct 

24. DISSECTION OF GALL BLADDER FROM LIVER Using the grasper the gall bladder is first retracted to right to expose and dissect the medial side of attachment  The gall bladder is then retracted to the left and the lateral side is dissected. Using the back and forth action ,the hook is used to dissect the gallbladder off the bed from the inferior to superior until the GB is removed from liver.

25. Extraction of gall bladder: The gallbladder Is now  freed from the liver and placed on top of the liver.  The patient is returned to the supine position and the area of dissection and the upper right quadrant are irrigated and suctioned until clear. The gallbladder is extracted through the 10-mm epigastric operating port with the help of gallbladder extractor.

26. CONT.. Sometimes big stones will not allow easy passage of gallbladder and in these situations, ovum forceps should be inserted inside the lumen of gallbladder through the incision of its neck and all the stone should be crushed  When ovum forceps is used to remove the big stones from the gallbladder, care should be taken that gallbladder should be held loose to have room for forceps, otherwise it will perforate and all the stone may spill out.

27. POST OPERATIVE CARE: Most of the patients can be discharged 6 hours after the  surgery or on the next day.  The patient who has urinary retention, prolonged nausea, more pain, or difficulty in  walking can be discharged after bowel sound.  Three doses of broad-spectrum antibiotic should be administered. First  dose infused 1 hour before surgery, second and third It is should be administered on consecutive days Few patients  may complain pain over tip of shoulder after laparoscopic surgery. This is due to irritation of diaphragm from CO₂. Tramadol hydrochloride is advised in these patients.

28. COMPLICATIONS:

29. COMPLICATIONS: LATE Biliary strictures Cystic duct clip stones

30. THANK YOU.