Laproscopic surgery


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Rawalpindi Medical college

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    As stated previously, lap chole was the first procedure performed using the Harmonic Scalpel. The Dissecting Hook blade is an effective instrument for dissection and transection of the cystic duct and artery once they are clipped.
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    Larger vessels (1-2mm) can be successfully coagulated using the side or back of the hook blade prior to rotating to transect.
    The cavitational effect of the Harmonic Scalpel aids in visualization of tissue planes by lifting the peritoneal surface off the gallbladder in front of the activated blade, as demonstrated in the second picture. Notice the lack of char and desiccation.
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    The surgeon enters into the tissue plane with the assistance of ultrasonic cavitation and cleanly separates the gallbladder from the liver.
    As depicted, the back side of the hook blade is especially helpful for cleaning up small bleeders on the back of the liver bed. The Ball Coagulator is also available to touch up surface or deep sinusoid bleeding after the gallbladder has been removed.
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  • Laproscopic surgery

    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