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Laparoscopy Basics, Principles, Instrumentation, Indication
 

Laparoscopy Basics, Principles, Instrumentation, Indication

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    Laparoscopy Basics, Principles, Instrumentation, Indication Laparoscopy Basics, Principles, Instrumentation, Indication Presentation Transcript

      • “ LAPAROSCOPY BASICS, PRINCIPLES, INSTRUMENTATION, & INDICATION”
      • Dr. Anil haripriya
      • Assitant Professor
      • General Surgery
      • NHDC & RI
    • INTRODUCTION
      • MIS & LS are currently are currently being increasingly used for wider & wider application
      • It is necessary to have a knowledge of its basic procedures, limitations & indications
    • HISTORY
      • Celioscopy
      • Peritoneoscopy
      • Laproscopy
    • HISTORY   1901 Kelling Ist laproscopic examination of abdominal cavity in rats called it CELIOSCOPY 1911 Jacobeus Ist human laproscopy 1938 Veress Spring loaded obturator needle for pneumoperitoneum 1966 Hopkins ***Developed Rod Lens Optical system 1960-70 Semm Developed automatic insufflator & instruments. Ist lap appendisectomy. Father of modern laproscopic surgery 1987 Philip Mouret 1 st L.C.
    • EQUIPMENT & INSTRUMENTATION
      • OPTICS
      • ABDOMINAL ACCESS INSTRUMENTS
      • LAPROSCOPIC INSTRUMENTS
    • OPTICS
      • I – ROD LENS SYSTEM
      • In 1960’s – Small lenses interspresed with large distance of air
      • Harold Hopkin Rod Lens System (1966)
      • Diameter of lens 1-5.5 mm
    •  
    • OPTICS
      • II – FIBER OPTIC CABLES
      • Composed of innercore of glass of high RI & a fused sheathing of low RI
      • Incoherent bundles have random arrangement of fibers at either end
      • Coherent bundles – orderly arrangement of fibers
    • OPTICS
      • III – LIGHT SOURCES
      • Tungsten bulb
      • Xenon bulb (1000 hrs) – produces white light & less heat
      • Halogen bulb (300-400 hrs) – produces yellow light & more heat
      • Halide bulb (150 hrs)
    • VIDEO IMAGING SYSTEM
      • Essential component is CCD
      • CCD – Equivalent to electronic retina
      • Comprises of pixels
      • Minimal resolving power of video camera is determined by number of pixels in CCD which is 400 lines of resolution /inch
      • Three chip video camera has 700 lines per inch with improved chromatic accuracy
    •  
    • ABDOMINAL ACCESS INSTRUMENTS
      • Open Technique Closed technique
      • Hasson cannula - Veress needle
      • - Trocar sheath
      • assemblies
    • VERESS NEEDLE
      • Obtains pneumoperitoneum by closed technique
      • Spring loaded obturator needle
      • Drawbacks:
        • Preperitoneal placement
        • Injury to vessels
        • Injury to bowel
    • TROCARS SHEATH
      • Reusable
      • Disposable
      • Hassons Cannula – obtains pneumoperitoneum by open technique
    • INSUFFLATORS
      • Automatic
      • Pressure regulated high flow
      • Monitor intrabdominal pressure which is usually set at 12-15 mmHg
      • Alarm sound or pressure release valves when pressure limit is exceeded
      • Flow rate of 8-10 lts/min
    • LAPROSCOPES
      • Rigid & Flexible
      • Based on Hopkins rod lens system
      • Sizes – 3-10 mm upto 18 mm
      • Angles
      • 0 0 / end on/ front wing
      • Commonly used least amount of image distortion brightest image
      • 30 0 45 0
      • To look around corners
      • Difficult to use
      • Especially useful in advanced lap procedures
    • PHYSIOLOGIC CHANGES
      • Are due to pneumoperitoneum
      • Pneumoperitoneum
      • Required to create working space
      • Gases used :
        • Air
        • O 2
        • CO 2
        • N 2 O
        • He, Ne, Ar (newer)
    • CO 2
      • Advantage :
      • Does not support combustion or explosion
      • Rapidly absorbed,
      • Rapidly soluble -  chance of gas embolism
      • Disadvantage :
      • Not readily available
      • Hypercarbia
      • Causes peritoneal discomfort when used with LA
    • N 2 0
      • Advantages :
      • Readily available
      • Better analgesia
      • Physiologically inert
      • Hypercarbia not a problem
      • Non explosive
      • Decreased intraop entitled CO 2 & minute ventilation required to maintain homeostasis
      • Disadvantages :
      • Supports combustion
      • Absorbed slower than CO 2
    • PNEUMOPERITONEUM
      • Gas effects
      • With CO 2 respiratory acidosis
      • Hypercarbia – Tachycardia,  in vascular resistance,  BP, & myocardial O 2 demand
      • Cardiac arrhythmias – Bradycardia (MC)
      • Gas embolism – Sudden hypotension, Mill wheel murmur  end tidal CO 2
    • PRESSURE EFFECTS
      • Vasovagal attack – due to streching of peritoneum
      • CVS :
        •  VR, CO – due to pressure on IVC
        • Venous engorgement with endothelial damage of lower limb veins
      • DVT
      • RS
      •  lung compliance
      •  PIP,  risk of barotrauma
      • Mild V/Q mismatch
      • Atelectasis
      • Hypoxia
    • RENAL SYSTEM
      •  RBF, GFR, Urine output
      • Stimulation of ADH axis
    • LAPROSCOPIC METHODS
      • Results in attenuated Neuroendocrine & cytokine response compared with open technique
      • Reduced surgical injury reduces the impairment of post op immune function specifically related to CMI
      • As evidenced by response to delayed hypersensitivity to PHA, WBC counts, IL-6 levels at day 1 & 6 of operation
    • CURRENT STATUS
      • Today & accepted
        • Cholecystectomy (Gold Standard)
        • Appendisectomy
        • Diagnostic laproscopy
        • Staging of malignancy
    • ADVANCED
      • Hernia repair
      • Nissens fundoplication
      • Hellermyotomy
      • Esophagectomy
      • Bile duct exploration
      • Splenectomy
      • Colectomy
      • APR
      • Rectal prolapse
      • Pancreatectomy
      • Liver resections
    • TOMORROW
      • Robotic assistance
      • Telepressence surgery
    • CONTRAINDICATION
      • Absolute
        • Uncorrectable coagulopathy
        • Frozen abdomen
        • Intestinal obstruction with massive abdominal distension
        • Haemorragic shock
        • Severe cardiac dysfunction (class IV)
        • Concomitant disease requiring laprotomy
    • RELATIVE
      • Inability to tolerate GA
      • Abdominal sepsis/ peritonitis
      • Multiple previous abdominal operations
      • Severe COPD
      • Pregnancy
      • Diphragmatic hernia
      • Morbid obesity
    • COMPLICATIONS
      • Insertion related
        • Major vascular injury (0.25%)
        • GI injury (0.14%)
        • Bladder injury
        • CO 2 embolism
        • Abdominal wall haemorrhage
    • POST INSERTIONAL COMPLICATIONS
      • GI perforations (acute or delayed)
      • Laceration & bleeding from solid organs
      • Abdominal wall hernia
    • PNEUMOPERITONEAL RELATIVE COMPLICATIONS
      • CO 2 embolism
      • Hypercarbia
      • Respiratory acidosis
      • Subcutaneous emphysema
      • Renal failure
      • Venous thrombosis
      • Pneumothorax
    • CREDENTIALING & TRAINING
      • Rapid acceptance
      • Market driven public demand has created unprecendented challenges in training & credentialing within these field
      • No formal training programme during surgical residency
    • KEY POINTS
      • Laproscopy has been used since a century but in last two decades there has been an explosion in these field
      • As new & new technology is coming up day by day its indications are also increasing
      • But laproscopy does not change indications of any operation & should be done only when it is indicated
      • Adequate training & caution are key points in laproscopic surgery
    • THANK YOU