Principles of laparoscopic surgery and pneumoperitonium

1. PRICIPLES OF LAPAROSCOPIC SURGERY
AND PNEUMOPERITONIUM
PREPARED BY:DR SAMRAT
SHRESTHA

2. Advantages of Laparoscopic Surgery
Reduced postoperative pain
Improved post operative mobilization  return to activity quicker
Small scar  less chance of hernia/cosmetic
Reduced wound infections
Reduced hospital stay

3. Analyzed 76,445 cases of gastrectomy.
LS was associated with fewer surgical wound infections, minor abdominal infections and
abscesses, cases of surgery-related peritonitis, repair surgeries, reoperations , less antibiotic use,
and shorter hospital stays.
However, average medical cost was 444 US dollar higher for LS than OS.

4. Ventilatory and Respiratory Changes
During Laparoscopy
Pneumoperitoneum decreases thoracopulmonary compliance
Reduction in FRC
Development of atelectasis due to elevation of the diaphragm
Capnography and pulse oximetry provide reliable for monitoring of Paco2 and arterial O2
saturation.
Postoperative intra-abdominal CO2 retention results in increased RR and ETCO2.
CO2 subcutaneous emphysema-complication of accidental extraperitoneal insufflation.

5. Hemodynamic Problems
During Laparoscopy
Peritoneal insufflation to IAPs higher than 10 mm Hg induces:
Reflex increases of vagal tone
Arrhythmias
Decreased CO-proportional to increase in IAP
Increased arterial pressures.
Elevation of systemic and pulmonary vascular resistances.

6. Increased IAP results in caval compression, pooling of blood in the legs, increase in venous
resistance.
The decline in VR, which parallels the decrease in CO, is confirmed by a reduction in left
ventricular end-diastolic volume measured using transesophageal echocardiography

8. Effect of CO2 pneumoperitoneum on renal function:-
Decrease in Urine output, RPF, GFR
Urine output significantly increases after deflation.

9. Cardiac Arrhythmias During Laparoscopy
Reflex increases of vagal tone from sudden stretching of the peritoneum
Bradycardia, cardiac arrhythmias, and asystole
Vagal stimulation is accentuated if the level of anesthesia is too superficial or if the patient is
taking β-blocking drugs.
Events are easily and quickly reversible.
Treatment- interruption of insufflation, atropine administration, and deepening of anesthesia
after recovery of the heart rate.

10. POSITIONING
Trendelenberg:
◦ Advantage: ↑ Venous return  Less hemodynamic stress
◦ Disadvantages:
◦ ↑ ITP  Decrease lung compliance
◦ Increased venous pressure and stasis in the head may cause falsely decreased SpO2 reading and poor
wave form.
◦ Debatable risk of ↑ ICP; ↑ ICP from steep trendelenberg has been shown to cause choroidal
vasodilation  ↑ ICP and ↑ IOP
Reverse Trendelenberg:
◦ Advantage: Improved lung compliance
◦ Disadvantage: ↓ Venous return  HD stress and blood pooling ↑ DVT risk

11. Proper positioning and adequate padding to prevent neuropathies.
Not to extend arm >90 degree to prevent brachial plexus injury

12. Port placement
Location of port sites depends on the type of procedure
Primary port is not always at the umbilicus
Judge which site is best for camera or which is safest site for primary puncture in a previously
operated abdomen.
Secondary ports should not be placed too close to each other.
Optimal pattern of port placement should form an equilateral triangle or a
diamond array around operative field

15. In laparoscopy, standard instrument length is 30 cm.
To produce a 1:1 translation and movement from surgeon’s hands to operative field, fulcrum
of instrument should be 15 cm from target.
Similar separation of 2 working ports (surgeon’s left and right hands) ensures that these 2
instruments will not be involved in “sword fighting”
Angle between the 2 instruments at target will be optimal (between 60 and 90 degrees).
During the procedure, area beneath the primary trocar site is inspected for unexpected
injuries.

17. GAS USED IN PNEUMOPERITONEUM
CO2 gas commonly used.
Noncombustible
Rapidly absorbed from the peritoneal cavity
Readily available
Cheaper
Quickly released via respiration
May lead to hypercarbia in patients with significant cardiopulmonary disease.

18. OTHER GAS FOR PNEUMOPERITONIUM
Helium
Argon
Nitrogen
Nitrous oxide
Room air

19. Pneumoperitoneum can be established by:
oClosed CO2 insufflated into the peritoneal cavity through a Veress
needle placed blindly into the abdominal cavity.
oOpen technique Laparoscopic port is inserted under direct vision
into the peritoneal cavity via a small incision
Pneumoperitoneum is established only after ensuring definitive and
safe peritoneal entry
oDirect Trocar insertion

20. REUSABLE 80 MM LONG VERESS NEEDLE
SPRING LOADED INNER STYLET SHOWN SEPARATELY

21. CLOSED/VERESS NEEDLE TECHNIQUE
SITE:
1. In unoperated abdomen-usually at the level of umbilicus
2. Previous laparotomy incisions with presumed adhesions-more lateral approach which avoids
the epigastric vessels.
3. Palmer’s point- LUQ, in patient with periumbilical adhesion or periumbilical hernia.3 cm
below left subcostal border, just lateral to rectus muscle in MCL.
4. 9TH left intercostal space.
5. Lateral border of rectus muscle at level of iliac crest.

22. PALMER’S POINT

23. Abdominal wall on either side of umbilicus is grasped either by thumb and forefinger or
by towel clips-to elevate the abdominal wall.

24. 1-cm vertical or horizontal skin incision is made
Veress needle is held like a pencil in between the
thumb and the index and middle finger at 45 degree
angle directed towards the pelvis.

25. Ring finger is placed to act as a guard to prevent excessive entry of needle into the peritoneal
cavity.
Insert it through the linea alba.
Two clicks
1. Entry through the linea alba
2. Peritoneum is penetrated.

26. Unobstructed Free intraperitoneal position for veress needle is verifed by
Hanging drop method
Aspirate the needle with a 10 mL syringe
Introduce about 10 mL of saline through the needle:If the needle
is in peritoneal cavity the saline would flow freely and no saline
could be aspirated back.

27. Insufflator tubing is connected to the Veress needle
CO2 is insufflated at a low flow rate of approximately 1 L/min with a low-pressure limit of
approximately 5 to 7 cm H2O.
Initial pressure should not increase appreciably during the early phase of insufflation.
Asymmetric distension, a rapid increase in pressure with low insufflated volume, or an initial
pressure greater than 10 mm Hg suggests that the needle is not in the proper position.
Abdomen is fully insufflated with the upper pressure limit set at 12 to 15 mm Hg; this usually
requires 3 to 6 L of carbon dioxide
If IAP> 20 mm Hg, CVP & BP decrease because of decreased VR and diminished CO.

28. Once 1 to 2 L o CO2 are in, the abdomen should be hyperresonant to percussion.
3-4L of CO2 are required to fully inflate the abdomen and the Veress needle is removed.
After grasping either side of umbilicus, a 10-mm trocar port is inserted with a twisting
motion, aiming toward the pelvis.

29. After the pneumoperitoneum- Replace Veress needle with a trocar
through a periumbilical incision into which the
Laparoscope may be inserted.
Port is inserted by manually elevating the
abdominal wall to avoid iatrogenic injury
to intraabdominal viscera or retroperitoneal
structures.

30. GAS EMBOLISM
During the initial period of insufflation, the patient must be monitored closely for signs of gas
embolism:-
Hypotension
Decreased O2 saturation
Decreased ETCO2
“Mill-wheel” heart murmur
Vagal reaction (hypotension, bradycardia)
Ventricular arrhythmias
Hypercarbia with acidosis.

32. Safe in experienced hand
 Quick to perform
Blind technique
Higher incidence of injuries due to blind introduction of veress needle or the 1st trocar
insertion.
Bladder, bowel or vascular injury.

33. HASSONS TROCAR
M/C employed at the central umbilical site.

34. 10-12mm skin incision at infra/supraumbilical skin fold.
Subcutaneous fat and tissues are bluntly dissected
White linea alba is visualized.
Kocher clamps are applied to both sides of the linea alba
Linea alba is elevated with hemostats-vertical 10-mm incision is made through fascia to gain
access to the peritoneal cavity.

36. Further dissection to reveal white peritoneum-grasped with a pair of
laterally placed hemostats.
Peritoneum is elevated and opened cautiously with a scalpel
 Dark, empty peritoneal space seen and a pair of lateral stay sutures
are placed.
Sutures will incorporate the peritoneum and linea alba and are later
used to secure the Hasson port.

37. Next step-verify that the intraperitoneal space
has been entered freely.
Surgeon’s fifth finger is inserted to palpate region.
Any filmy omental adhesions can be swept away.

38. Hasson port with it’s blunt , rounded- tip
obturator is introduced.
Spiral collar is screwed into the fascia-provide a snug gas seal.
Lateral stay sutures secured on notches on the collar.
Obturator removed.
CO2 line is attached --stopcock opened.
CO2 flow and pressure set(pressure12-15 mm Hg)

40. HOW TO INTRODUCE TROCAR?
Top of the trocar rests on the palm and the trocar and cannula is held in between fingers.
Inserted by rotatory movement till loss of resistance is felt.
Telescope attached to the camera is inserted.
Subsequent trocars are inserted under vision.

41. HASSONS OPEN TECHNIQUE
TIME CONSUMING
MORE RISK OF PORT SITE HERNIA
RISK OF INJURY TO INTRAABDOMINAL AND
VASCULAR STRUCTURE IS LESS.
VERESS CLOSED TECHNIQUE
QUICK ENTRY
REDUCED RISK OF PORT SITE HERNIA
RISK OF INJURY TO INTRAABDOMINAL AND
VASCULAR STRUCTURE.

43. FASCIAL CLOSURE
Incident of Portsite hernias 0.65% to 2.80%
All defects created with a 10-mm or greater bladed trocar should be closed
When a port is manipulated excessively or has to be replaced multiple times, there may be a
larger than expected fascial defect that may require closure.
Place ports lateral to the rectus muscles when possible.
Removal of ports from abdomen should be observed to be certain that omentum or abdominal
contents are not brought up through the abdominal wall.

44. The total number of patients in all articles was 18,533
The overall trocar site hernia rate was 0.104%.
When comparing open vs. closed ports, there was no significant difference in the hernia incidence rate for 5-mm and 10-
mm ports.
When comparing bladed versus non-bladed trocars, there was a statistically significant difference with lower hernia
incidence rates for non-bladed trocars over bladed trocars for 5-mm, 10-mm, and 12-mm ports.
And when comparing trocar location from midline versus off-midline, there was a statistically significant higher TSH
incidence in midline trocar locations.

45. TROCAR INJURY
The overall risk of a trocar injury to intra-abdominal structures is estimated to be between 5 in 10,000 and 3 in
1000.
Almost all injuries occur during primary trocar insertion.
According to Chandler and colleagues, Most commonly injured organ is
1. Small bowel (25.4%)
2. Iliac artery (18.5%)
3. Colon (12.2%)
4. Iliac vein (8.9%)
5. Mesenteric vessels (7.3%)
6. Aorta (6.4%).
Mortality from trocar injury is 13%, with 44% owing to major vessel injury, 26% to bowel injury with delayed
diagnosis, and 20% to small bowel injury.

46. CHOICE OF TECHNIQUE
Controversy regarding safety -Hasson or Veress needle technique
Systematic review of randomized trials-no significant differences in overall complication rates
Retrospective reviews suggest that the risk of major complications is reduced with open access
techniques or placement of trocars with visual confirmation.

51. REFERENCES
Zollinger’s Atlas of Surgical Operations
Bedside Clinics in Surgery-Makanlal
IMAGES-Netter’s Atlas of Human Anatomy 7th Edition, UPTODATE
Maingot’s Abdominal operations.