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Laproscopic surgery

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Rawalpindi Medical college

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Laproscopic surgery

  1. 1. Principal of Laparoscopic Surgery PROFESSOR HAMID HASSAN PROFESSOR OF SURGERY SURGICAL UNIT – I, RGH.
  2. 2. Minimal Access Surgery is the marriage of the modern technology and Surgical Innovation.
  3. 3. Aims  Minimal Somatic trauma  Minimal Psychological Trauma  lesser Hospital Stay  Faster recuperation
  4. 4. Category  Laparoscopy.  Thoracoscopy.  Endoluminal endoscopy.  Perivisceral endoscopy.  Arthroscopy and Intra-articular Surgery.  Combined Approach.
  5. 5. Dimension of Laparoscopic Surgery  Diagnostic Laparoscopic Surgery     Non Specific Abdominal Pain B.A.T Staging of Intra abdominal Malignancy Secondary Infertility in Females
  6. 6.  Therapeutic Laparoscopic Surgery       Lap. Cholecystectomy Lap. Spleenectomy Lap Thyroidectomy Lap. Ligation of Varicose vein perforators Lap. Cardiac bypass surgery Lap. Biopsy taken from Lungs and Liver
  7. 7. Dif ferent Instr ument use in Laparoscopic Sur ger y
  8. 8. Blunt Tip Trocar Trocar sleeve Blunt tip Adjustable olive Desufflation lever Suture tie point Cam Stopcock Locking button Obturator handle
  9. 9. Dilating Tip Surgical Trocar *trademark
  10. 10. Curved Intraluminal Staplers with Detachable Head
  11. 11. CONVENTIONAL LIGATION LIGACLIP* Multiple Clip Appliers ABSOLOK* EXTRA Absorbable Single Clip System LIGACLIP* EXTRA Single Clip System
  12. 12. Skin Stapler
  13. 13. PROXIMATE* Linear Cutters
  14. 14. Preoperative Evaluation
  15. 15. Aims  The patient is fit for surgery  The patient is fully informed and consented  Operative difficulty is predicted where possible  Appropriate theater time and facilities available
  16. 16.  History  Examination  Premedication
  17. 17.  Prophylaxis against Thromboembolism  Informed consent  Urinary catheter and NG tube if needed.
  18. 18. General Intraoperative Principles
  19. 19. Assistant Nurse Scrub Surgeon Instrument Table Anesthesia Mayo Stand Operation Theater Setup Monitor
  20. 20. Creating a Pneumoperitonium
  21. 21. Preoperative Problems  Previous Abdominal Surgery  Obesity
  22. 22. Operative Problems  Perforation of hollow viscus  Bleeding  From Major Vessel  From Gall Bladder Bed  From Trocar Site How to Evacuate the Clot ?
  23. 23. Principal of Electrosurgery during Laparoscopic Surgery
  24. 24. ©19 95 Eth ico n En do -S urg ery , In c..  Monopolar diathermy  Bipolar Diathermy Electrosurgery Electrical Injuries unrecognized at the time of operation patient present after about 3 -7 days with abdominal pain and fever.
  25. 25. Causes of injury  Inadvertent touching and grasping.  Direct coupling between the tissue and the instrument.  Break in insulation.
  26. 26.  Direct sparking to bowel from the diathermy probe.  Passage of current to the bowel from recently coagulated tissue.
  27. 27. Postoperative Care
  28. 28.  Nausea  Shoulder Pain  Abdominal Pain  Analgesia
  29. 29.  Oral fluids  Oral feeding  Drains
  30. 30.  Mobility and Convalescence  Discharge from the Hospital  Skin Sutures.
  31. 31. Principal Of Common Laparoscopic Procedure
  32. 32. Laparoscopic Cholecystectomy Cystic duct Hartmann’s pouch (infundibulum) Gallbladder Liver margin Hepatic ducts Common hepatic duct Sphincter of Oddi Fundus Duodenum Duodenal wall Ampulla of Vater Common bile duct Pancreatic duct Duodenal papilla
  33. 33. Left hepatic artery Portal vein Proper hepatic artery Liver Common hepatic artery Ligamentum teres Left gastric artery Common hepatic duct Right hepatic artery Celiac trunk Splenic artery Gallbladder Cystic artery Cystic duct Pancreas Common bile duct Abdominal aorta Gastroduodenal artery Superior mesenteric vein Superior mesenteric artery
  34. 34. Video monitor Light source Camera VCR Suction unit CO2 insufflator in CO su ff 2 la to r Anesthesia se ur N Instrument stand Surgeon Assistant V m id on eo ito r Electrocautery unit Suction unit
  35. 35. 5mm trocar midclavicular 5mm trocar anterior axillary 5mm or 10/12mm trocar subxiphoid 10/11mm or 10/12mm trocar umbilicus Port Placement
  36. 36. Laparoscopic Cholecystectomy (Hook)  Use the hook blade to dissect cystic duct and artery  Ligate with clips  Transect with hook blade
  37. 37.  Use side of hook for coaptive coagulation prior to transaction Cavitationally assisted dissection off the liver bed
  38. 38.  Back or side of hook blade for small bleeders on the liver bed
  39. 39. Laparoscopic Inguinal Hernia  Trans Abdominal Preperitoneal repair  Extraperitoneal repair
  40. 40. Rectus abdominis Medial umbilical ligament Hesselbach’s triangle Lacunar (Gimbernat’s) ligament Urinary bladder Vas deferens Ureter Inferior epigastric vessels Internal inguinal ring Cooper’s ligament Iliopubic tract Testicular vessels External iliac vessels Cecum Sacral promontory
  41. 41. Laparoscopic Antireflux Surgery
  42. 42. Esophagus Phrenoesophageal ligament (ascending or upper limb) Respiratory diaphragm Phrenoesophageal ligament (ascending or upper limb) Infradiaphragmatic fascia Phrenoesophageal ligament (descending limb) Visceral peritoneum Subhiatal fat ring Phrenoesophageal ligament (descending limb) Fundus of stomach Visceral peritoneum Ligaments of the Esophageal Hiatus (anterior view)
  43. 43. Nissen Fundoplication Anesthesia Monitor Assistant First Assistant Instrument Table Monitor Surgeon
  44. 44. 5 or 10/12mm trocar operating port 10/12mm trocar operating port 5 or 10/12 mm trocar liver retraction 10/12mm trocar stomach retraction umbilicus 10/12mm trocar camera port Port Placement
  45. 45. NISSEN FUNDOPLICATION Fig. 1 Liver
  46. 46. Fig. 2 Crura
  47. 47. Fig. 3 Short gastric vessels divided
  48. 48. Fig. 4 Wrap created
  49. 49. Fig. 5 Wrap fixated
  50. 50. Laparoscopic Spleenectomy
  51. 51. Greater curvature of vascular arcade Stomach (posterior surface) Left gastric artery Greater omentum Splenic artery Caudate lobe of liver Spleen Left gastroepiploic artery Proper hepatic artery Inferior vena cava Superior pole of kidney Gastroduodenal artery Right gastroepiploic artery Duodenum Pancreas Celiac trunk Common hepatic artery Greater omentum Anterior superior pancreaticoduodenal artery Left suprarenal gland
  52. 52. Spleenic Artery Anatomy
  53. 53. Division of short gastric vessels
  54. 54. Division of short gastric vessels
  55. 55. Division of short gastric vessels
  56. 56. Dissection of Spleenic Vessels
  57. 57. Ligating Spleenic Artery
  58. 58. Divided splenic artery and vein
  59. 59. Exposure of Inferior Pole Ligaments
  60. 60. Direct Approach to Hilium
  61. 61. Division of Hilum with Endoscopic Stapler
  62. 62. Completion of Spleenectomy
  63. 63. Spleen Placed in Bag
  64. 64. Bagged Spleen
  65. 65. Removed Spleen
  66. 66. Cannula Sites
  67. 67. Future Of Laparoscopic 1. 2. 3. 4. Gas less Laparoscopic Surgery Hand assisted Laparoscopic Surgery Natural Orifice Transluminal Endoscopic Surgery (NOTES) is being investigated as an alternative to laparoscopy. Laparoscopic surgery utilizing the computer robot system

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