Laparoscopy Basics, Principles, Instrumentation, Indication

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Laparoscopy Basics, Principles, Instrumentation, Indication

  1. 1. <ul><li>“ LAPAROSCOPY BASICS, PRINCIPLES, INSTRUMENTATION, & INDICATION” </li></ul><ul><li>Dr. Anil haripriya </li></ul><ul><li>Assitant Professor </li></ul><ul><li>General Surgery </li></ul><ul><li>NHDC & RI </li></ul>
  2. 2. INTRODUCTION <ul><li>MIS & LS are currently are currently being increasingly used for wider & wider application </li></ul><ul><li>It is necessary to have a knowledge of its basic procedures, limitations & indications </li></ul>
  3. 3. HISTORY <ul><li>Celioscopy </li></ul><ul><li>Peritoneoscopy </li></ul><ul><li>Laproscopy </li></ul>
  4. 4. 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.
  5. 5. EQUIPMENT & INSTRUMENTATION <ul><li>OPTICS </li></ul><ul><li>ABDOMINAL ACCESS INSTRUMENTS </li></ul><ul><li>LAPROSCOPIC INSTRUMENTS </li></ul>
  6. 6. OPTICS <ul><li>I – ROD LENS SYSTEM </li></ul><ul><li>In 1960’s – Small lenses interspresed with large distance of air </li></ul><ul><li>Harold Hopkin Rod Lens System (1966) </li></ul><ul><li>Diameter of lens 1-5.5 mm </li></ul>
  7. 8. OPTICS <ul><li>II – FIBER OPTIC CABLES </li></ul><ul><li>Composed of innercore of glass of high RI & a fused sheathing of low RI </li></ul><ul><li>Incoherent bundles have random arrangement of fibers at either end </li></ul><ul><li>Coherent bundles – orderly arrangement of fibers </li></ul>
  8. 9. OPTICS <ul><li>III – LIGHT SOURCES </li></ul><ul><li>Tungsten bulb </li></ul><ul><li>Xenon bulb (1000 hrs) – produces white light & less heat </li></ul><ul><li>Halogen bulb (300-400 hrs) – produces yellow light & more heat </li></ul><ul><li>Halide bulb (150 hrs) </li></ul>
  9. 10. VIDEO IMAGING SYSTEM <ul><li>Essential component is CCD </li></ul><ul><li>CCD – Equivalent to electronic retina </li></ul><ul><li>Comprises of pixels </li></ul><ul><li>Minimal resolving power of video camera is determined by number of pixels in CCD which is 400 lines of resolution /inch </li></ul><ul><li>Three chip video camera has 700 lines per inch with improved chromatic accuracy </li></ul>
  10. 12. ABDOMINAL ACCESS INSTRUMENTS <ul><li>Open Technique Closed technique </li></ul><ul><li>Hasson cannula - Veress needle </li></ul><ul><li>- Trocar sheath </li></ul><ul><li>assemblies </li></ul>
  11. 13. VERESS NEEDLE <ul><li>Obtains pneumoperitoneum by closed technique </li></ul><ul><li>Spring loaded obturator needle </li></ul><ul><li>Drawbacks: </li></ul><ul><ul><li>Preperitoneal placement </li></ul></ul><ul><ul><li>Injury to vessels </li></ul></ul><ul><ul><li>Injury to bowel </li></ul></ul>
  12. 14. TROCARS SHEATH <ul><li>Reusable </li></ul><ul><li>Disposable </li></ul><ul><li>Hassons Cannula – obtains pneumoperitoneum by open technique </li></ul>
  13. 15. INSUFFLATORS <ul><li>Automatic </li></ul><ul><li>Pressure regulated high flow </li></ul><ul><li>Monitor intrabdominal pressure which is usually set at 12-15 mmHg </li></ul><ul><li>Alarm sound or pressure release valves when pressure limit is exceeded </li></ul><ul><li>Flow rate of 8-10 lts/min </li></ul>
  14. 16. LAPROSCOPES <ul><li>Rigid & Flexible </li></ul><ul><li>Based on Hopkins rod lens system </li></ul><ul><li>Sizes – 3-10 mm upto 18 mm </li></ul><ul><li>Angles </li></ul><ul><li>0 0 / end on/ front wing </li></ul><ul><li>Commonly used least amount of image distortion brightest image </li></ul><ul><li>30 0 45 0 </li></ul><ul><li>To look around corners </li></ul><ul><li>Difficult to use </li></ul><ul><li>Especially useful in advanced lap procedures </li></ul>
  15. 17. PHYSIOLOGIC CHANGES <ul><li>Are due to pneumoperitoneum </li></ul><ul><li>Pneumoperitoneum </li></ul><ul><li>Required to create working space </li></ul><ul><li>Gases used : </li></ul><ul><ul><li>Air </li></ul></ul><ul><ul><li>O 2 </li></ul></ul><ul><ul><li>CO 2 </li></ul></ul><ul><ul><li>N 2 O </li></ul></ul><ul><ul><li>He, Ne, Ar (newer) </li></ul></ul>
  16. 18. CO 2 <ul><li>Advantage : </li></ul><ul><li>Does not support combustion or explosion </li></ul><ul><li>Rapidly absorbed, </li></ul><ul><li>Rapidly soluble -  chance of gas embolism </li></ul><ul><li>Disadvantage : </li></ul><ul><li>Not readily available </li></ul><ul><li>Hypercarbia </li></ul><ul><li>Causes peritoneal discomfort when used with LA </li></ul>
  17. 19. N 2 0 <ul><li>Advantages : </li></ul><ul><li>Readily available </li></ul><ul><li>Better analgesia </li></ul><ul><li>Physiologically inert </li></ul><ul><li>Hypercarbia not a problem </li></ul><ul><li>Non explosive </li></ul><ul><li>Decreased intraop entitled CO 2 & minute ventilation required to maintain homeostasis </li></ul><ul><li>Disadvantages : </li></ul><ul><li>Supports combustion </li></ul><ul><li>Absorbed slower than CO 2 </li></ul>
  18. 20. PNEUMOPERITONEUM <ul><li>Gas effects </li></ul><ul><li>With CO 2 respiratory acidosis </li></ul><ul><li>Hypercarbia – Tachycardia,  in vascular resistance,  BP, & myocardial O 2 demand </li></ul><ul><li>Cardiac arrhythmias – Bradycardia (MC) </li></ul><ul><li>Gas embolism – Sudden hypotension, Mill wheel murmur  end tidal CO 2 </li></ul>
  19. 21. PRESSURE EFFECTS <ul><li>Vasovagal attack – due to streching of peritoneum </li></ul><ul><li>CVS : </li></ul><ul><ul><li> VR, CO – due to pressure on IVC </li></ul></ul><ul><ul><li>Venous engorgement with endothelial damage of lower limb veins </li></ul></ul><ul><li>DVT </li></ul><ul><li>RS </li></ul><ul><li> lung compliance </li></ul><ul><li> PIP,  risk of barotrauma </li></ul><ul><li>Mild V/Q mismatch </li></ul><ul><li>Atelectasis </li></ul><ul><li>Hypoxia </li></ul>
  20. 22. RENAL SYSTEM <ul><li> RBF, GFR, Urine output </li></ul><ul><li>Stimulation of ADH axis </li></ul>
  21. 23. LAPROSCOPIC METHODS <ul><li>Results in attenuated Neuroendocrine & cytokine response compared with open technique </li></ul><ul><li>Reduced surgical injury reduces the impairment of post op immune function specifically related to CMI </li></ul><ul><li>As evidenced by response to delayed hypersensitivity to PHA, WBC counts, IL-6 levels at day 1 & 6 of operation </li></ul>
  22. 24. CURRENT STATUS <ul><li>Today & accepted </li></ul><ul><ul><li>Cholecystectomy (Gold Standard) </li></ul></ul><ul><ul><li>Appendisectomy </li></ul></ul><ul><ul><li>Diagnostic laproscopy </li></ul></ul><ul><ul><li>Staging of malignancy </li></ul></ul>
  23. 25. ADVANCED <ul><li>Hernia repair </li></ul><ul><li>Nissens fundoplication </li></ul><ul><li>Hellermyotomy </li></ul><ul><li>Esophagectomy </li></ul><ul><li>Bile duct exploration </li></ul><ul><li>Splenectomy </li></ul><ul><li>Colectomy </li></ul><ul><li>APR </li></ul><ul><li>Rectal prolapse </li></ul><ul><li>Pancreatectomy </li></ul><ul><li>Liver resections </li></ul>
  24. 26. TOMORROW <ul><li>Robotic assistance </li></ul><ul><li>Telepressence surgery </li></ul>
  25. 27. CONTRAINDICATION <ul><li>Absolute </li></ul><ul><ul><li>Uncorrectable coagulopathy </li></ul></ul><ul><ul><li>Frozen abdomen </li></ul></ul><ul><ul><li>Intestinal obstruction with massive abdominal distension </li></ul></ul><ul><ul><li>Haemorragic shock </li></ul></ul><ul><ul><li>Severe cardiac dysfunction (class IV) </li></ul></ul><ul><ul><li>Concomitant disease requiring laprotomy </li></ul></ul>
  26. 28. RELATIVE <ul><li>Inability to tolerate GA </li></ul><ul><li>Abdominal sepsis/ peritonitis </li></ul><ul><li>Multiple previous abdominal operations </li></ul><ul><li>Severe COPD </li></ul><ul><li>Pregnancy </li></ul><ul><li>Diphragmatic hernia </li></ul><ul><li>Morbid obesity </li></ul>
  27. 29. COMPLICATIONS <ul><li>Insertion related </li></ul><ul><ul><li>Major vascular injury (0.25%) </li></ul></ul><ul><ul><li>GI injury (0.14%) </li></ul></ul><ul><ul><li>Bladder injury </li></ul></ul><ul><ul><li>CO 2 embolism </li></ul></ul><ul><ul><li>Abdominal wall haemorrhage </li></ul></ul>
  28. 30. POST INSERTIONAL COMPLICATIONS <ul><li>GI perforations (acute or delayed) </li></ul><ul><li>Laceration & bleeding from solid organs </li></ul><ul><li>Abdominal wall hernia </li></ul>
  29. 31. PNEUMOPERITONEAL RELATIVE COMPLICATIONS <ul><li>CO 2 embolism </li></ul><ul><li>Hypercarbia </li></ul><ul><li>Respiratory acidosis </li></ul><ul><li>Subcutaneous emphysema </li></ul><ul><li>Renal failure </li></ul><ul><li>Venous thrombosis </li></ul><ul><li>Pneumothorax </li></ul>
  30. 32. CREDENTIALING & TRAINING <ul><li>Rapid acceptance </li></ul><ul><li>Market driven public demand has created unprecendented challenges in training & credentialing within these field </li></ul><ul><li>No formal training programme during surgical residency </li></ul>
  31. 33. KEY POINTS <ul><li>Laproscopy has been used since a century but in last two decades there has been an explosion in these field </li></ul><ul><li>As new & new technology is coming up day by day its indications are also increasing </li></ul><ul><li>But laproscopy does not change indications of any operation & should be done only when it is indicated </li></ul><ul><li>Adequate training & caution are key points in laproscopic surgery </li></ul>
  32. 34. THANK YOU

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