Principle of laparoscopic surgery

Topic presentation

1. Principles of Laparoscopic surgery Presenter : Dr. Annush Tha Moderator: Dr. DA/DB Department of Surgery Pokhara Academy of Health Sciences 2077-08-07

2. Principles of Laparoscopic surgery

3. Learning objectives Introduction Principles of laparoscopic surgery Advantages and disadvantages Safety issues Principles of postoperative care Recent advances in modern surgical practice

4. Minimally invasive surgery(MIS) Means of performing major operations through small incisions using miniaturized, high tech imaging systems to minimize the trauma of surgical exposure Coined by John Wickham Also known as laproscopic surgery or Minimal access surgery

5. Historical background 1901  1 st experimental laparoscopy procedure done by Georg Kelling  termed “ celioscopy “—examined abdominal cavity in dogs using cystoscope Hans Christian Jacobaeus  successfully applied minimal invasive techniques in human Coined the term “ laparoscopie ” and “ Thoracoscopie ” Bertram Berheim  from John Hopkins first performed laparoscopy in United States Patrick Steptoe applied this approach in 1980 in UK Philipe Mouret’s First video laparoscopic cholecystectomy ,Lyon-1987

6. Core principle of MIS (I-VITROS) I - insufflate/create space V- visualize-( anatomical landmark, tissue ,surgical environment) I - identify-( specific structures for surgery) T- triangulate(surgical tools to optimize efficiency, ergonomics, minimize crowding/clashing) R – retract ( manipulate and access the correct tissue plane) O- operate (incise, suture, anastomose) S – seal/Hemostasis

7. Advantages of minimal access surgery Decrease wound size Reduction in wound infection , dehiscence , bleeding , herniation and nerve entrapment Decrease wound pain Improved mobility Decreased wound trauma Decreased heat loss Improved visualisation

8. L imitations Reliance on remote vision and operating Dependence on hand eye coordination Difficult with hemostasis Reliance on new technique Extraction of large specimens Loss of tactile feedback Expertise and training required

9. MIS categories Laparoscopy Thoracoscopy Endoluminal endoscopy—urology, git , respiratory and vascular systems Perivisceral endoscopy- mediastinoscopy , retroperitoneoscopy , etc Arthoroscopy and intra-articular joint surgery Spectrum – Diagnostic/Therapeutic

10. Preparation for laparoscopic surgery Overall fitness of the patient: History and examination Previous surgery- scars, adhesions Body habitus: obesity, skeletal deformity Coagulation profile and thrombocytopenia Informed consent

11. Prerequisites for MIS Equipment and OR setup Technique Training

12. General intraoperative principles Patient positioning depending upon the surgical procedure Creating pneumoperitoneum Closed method Open method Physiologic effects of CO2 pneumoperitoneum Gas specific effects Pressure specific effects

13. Closed method Involves blind puncture using Verres needle Fast and relatively safe Potential risk for intestinal or vascular injury on introduction of the needle or first trocar Check verres needle for spring action and patency with NS

14. 1 cm horizontal or vertical incision at level of umbilicus Abdominal wall on both side grasped with finger/ allis forcep and raised Verres needle introduced at angle of 45° directing towards the pelvis or anus(or perpendicular to the abdominal wall) Popping sensation felt on piercing through linea alba and peritoneum Do irrigation test  aspiration test hanging drop test with NS(lift abdominal wall NS sucked in) Insufflate with CO2 gas up to maximum pressure 14-15mm of Hg Remove Verres needle and introduce 5-10 mm trocar

15. Open method/ Hasson method Definite and small risk of bowel injury Increasing number of surgeons performing laparoscopy without experience Useful in patients with abdominal surgery or underlying adhesions

16. Open / Hasson method 1cm vertical or transverse incision made at level of umbilicus(above or below) Retract and Blunt dissection to expose midline fascia Two sutures inserted on either side of midline incision and 1cm opening created in fascia Peritoneum identified and opened Finger introduced to verify free access to abdominal cavity (R/O bowel adhesion) Hasson trocar introduced and held with stay sutures at its wings Insufflation with CO2

17. Port placement Trocars for surgeons left and right hand placed at least 10 cm apart Ideal trocar orientation creates equilateral triangle between surgeons right hand, left hand and the telescope( Baseball Diamond configuration) Surgeon stands behind the telescope Inability to space trocars severely limits the ability to triangulate the left and right hand instruments

18. Preoperative problems Previous abdominal surgery Not a contraindication assesse the type and location of scars Open method for pneumoperitoneum Laparoscope used to as blunt dissector to traverse through adhesions By careful pushing and twisting motion under direct vision

19. Obesity Technically difficult on creating pneumoperitoneum —(coz of increased thickness of subcutaneous fat) accessing operative region and achieving good exposure in presence of an obese colon Overcome difficulties by: Use supra umblical incision large 1-3cm Direct verres needle at right angle to skin(if closed method used) Hasson method preferred Use larger and longer instruments to reach operative site

20. Operative problems Intraoperative perforation of viscus Bowel, solid organs and blood vessels Best is to avoid with utmost care and precision Antibiotics Prophlaxis with in 1 hour of skin incision Established sepsis or septicemia not recommend for MIS except for removing foci of infection

21. Bleeding Most common cause to conversion to open surgery Limits the field of operation Obscures the operative field Magnification confuses small arterial bleed as the significant hemorrhage Light absorption obscures the visual field Bleeding from major vessel Identify bleeder and achieve hemostasis with electrosurgery (diathermy) Good suction and irrigation well managed Use surgical if required Consider open procedure without delay if bleeding couldn’t be controlled

22. 2. Bleeding from organ Can be prevented if dissection is done in correct plane If bleeding from organ is noted  dissection is extended to locate the bleeding point  electrocautery  hemostasis Bleeding persists bleeding point grasped with insulated grasper electrocautery applied to grasper to achieve the hemostasis

23. 3. Bleeding from trocar site Controlled by applying upwards and lateral pressure with trocar Occurs if falciform ligament is pierced with substernal trocar or epigastric vessels are injured Monofilament suture attached to specialized needle passed into abdominal cavity and exited at other side of ligament using grasper Loop suspended and compression achieved during procedure  hemostasis remove loop after procedure under direct vision ensure hemostasis If significant bleeding occurs apply pressure or suture Pressure applied with foleys catheter entered into trocar site inflate balloon maintain in traction keep for 24 hours and remove

24. Post operative care Most common post op complains are Nausea Managed with antiemetics Controlled within 12-24 hours Avoid opiate analgesics Shoulder tip pain Referred from diaphragm, worst at 24hour after operation Settles within 2-3 days and controlled with paracetamol

25. Abdominal pain Port site pain present but worse if hematoma formation occurs Increasing pain after 2-3 days  suspect infection and run tests and treat appropriately with antibiotics Herniation through port site may produce localized pain If increasing pain, tachycardia or pyrexia review the case and relaparoscopy should be considered Oral fluids and food Started after 4-6hours post op except in colectomy or small bowel resection Light meal can be given

26. Catheter and drain Foleys if applied remove after procedure Drain applied to assess Post operative blood loss Nature of intraperitoneal fluid Postoperative monitoring needs Drain if placed to vent gas and peritoneal fluid  remove with in 1 hour after operation If placed for hepatic bleeding or bile leakage remove when drain has achieved its function (after 12-24 hours) If continued blood loss from drain re explore the abdomen

27. Special consideration Pediatric laparoscopy Laparaoscopy in infant and child requires specialized instruments Instruments are shorter (15-20cm )and 3mm in diameter( 5mm in adult) 5mm telescope (adult 10mm) Abdominal wall thinner– pneumoperitoneum 0.1L/min/Year(flow rate) up to 10 year 1L/min adult and 10yr after wards Pneumoperitoneum pressure 8mm of HG Used for colonic aganglionosis ( pull through procedure) , congenital diaphragmatic hernia repair, etc

28. During pregnancy Access to abdomen based on the height of uterine fundus which reaches the umbilicus at 20wks Timing of operation- 2 nd Trimester if possible Position –slight left lateral to avoid venacava compression Use Sequential compression device in all cases ( to avoid thromboembolism) Use Hassons technique for pneumoperitoneum Avoid maternal acidosis to prevent fetal acidosis( avoid hypercarbia ) Consider open procedures if fetal distress expected after pneumoperitoneum

29. Laparoscopy in elderly and infirm Older patients more likely to require conversion to celiotomy ( open surgery) Requires close monitoring of anesthesia Intraoperative management more difficult in laparoscopic > open surgery MIS improves mobility after surgery so reduces morbidity which are result of reduced mobility in elderly

30. Advances Robotic surgery Robot performs automated physical tasks according to direct human supervision, predefined program or set of guidelines using AI Assists the surgeon during procedure

31. Two categories exist: 1. Teleopreated system: Human surgeon performs the operation via a robot and its robotic instruments through televisual computerized platform either via onsite connections or remotely through internet 2. Image guided system Surgical robot completes a pre programmed surgical task which is guided by preoperative imaging and real-time anatomical constrains Follows inbuilt navigation system

32. Single incision Laparoscopic Surgery(SILS) All instruments inserted via single incision through multiple channel port via umbilicus to carry out procedure Benefit : Single opening via umbilicus– scarless Fewer ports so less pain, less risk of bleeding and reduced incidence o port site hernia

33. NOTES( Natural orifice translumenal endoscopic surgery) Entry into the peritoneal cavity via endoscopic puncture of a hollow viscus which is carried out via natural orifices Transvaginal , transvesiccle , transanal , transcolonic , transgastric and transoral approaches The ease of decontamination entry and closure of structures create a challenge Extraction GB,kidney , appendix, bladder, etc done via transvaginal route

34. Take home message MIS has advantages over the open procedure in terms scar, post operative pain and early return to work Requires sophisticated instruments and ample experience to perform the procedure correctly and safely Advances like SILS, Robotic surgery, NOTES are underway

35. References Bailey and love’s Short practice of Surgery-27 th Edition Schwartzs principles of Surgery -10 th Edition

36. Thank You