1) Laparoscopy was pioneered in the early 20th century and has since undergone many technological advancements. 2) Key components of a laparoscopic system include the light source, camera, monitors, insufflation system, and specialized instruments. 3) Proper patient positioning and port placement are important for ergonomics and optimal visualization during laparoscopic procedures.

1. BASICS OF LAPAROSCOPY
Prof. S. Subbiah et al

2. MILES STONE IN MINIMALLY INVASIVE SURGERY
YEAR CONTRIBUTOR SIGNIFICANCE
1706 “Trocar” from “Trochartor” troisequarts - 3
faced instrument consisting of a perforator
enclosed in a Metal cannula
1806 Philip Bozzini “LICHTLEITER” (aluminum tube to visualize
the genitourinary tract).
1910 Jacobaeus
(Stockholm)
Term “laparothorakoskopie” – procedure on
the thorax and abdomen
1920 Zollikofer
(Switzerland)
Benefit of CO2 gas, (filtered atmospheric air
or nitrogen)
1929 Heinz Kalk
(Germany)
Forward oblique (135°) view lens systems
1934 John C Ruddock
(America)
Laparoscopy for diagnostics
(Peritoneoscopy)
Prof. S. Subbiah et al

3. MILES STONE IN MINIMALLY INVASIVE SURGERY
YEAR CONTRIBUTOR SIGNIFICANCE
1938 Janos Veress (Hungary) Specially designed spring loaded needle
1953 Prof. Hopkins Rigid rod lens system
1960 Kurt Semm (Germany) Automatic insufflator
1977 Kurt Semm (Germany) Endo-loop suturing
1983 Kurt Semm (Germany) laparoscopic appendicectomy
1978 Hasson Alternative method of blunt trocar placement
1985 Erich Mühe (Germany) Laparoscopic cholecystectomy
1988 Harry Reich Laparoscopic lymphadenectomy (Ovarian cancer)
Prof. S. Subbiah et al

4. LAPARASCOPIC
IMAGING SYSTEM
1) Light source
2) Fiberoptic light cable
3) Laparoscope,
4) Camera head,
5) Video signal processor,
6) Video cable
7) Monitor
Prof. S. Subbiah et al

5. LIGHT SOURCE
• Different wattages “150 and 300
Watt” (type of procedure)
• 4 types of light source:
1. Halogen light source
2. Xenon light source
3. Metal halide light source
4. LED light source
Prof. S. Subbiah et al

6. LIGHT CABLE
• Fiberoptic cable (Total internal
reflection of light)
• Fiber size (20 to 150 micron)
• Avoid fiber breakage, the
curvature radius of light cable
should not <15 cm in radius.
Prof. S. Subbiah et al

7. • Distal end of fiberoptic cable
should never be placed on or
under drapes.
• The heat generated may cause
burns to the patient or ignite the
drapes
Thermal injury secondary to
laparoscopic fiber-optic cables
Surg Endosc (2009) 23:1720–1723 DOI
10.1007/s00464-008-0219-z
Prof. S. Subbiah et al

8. CAMERA HEAD
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9. TELESCOPE
• 2 types (Rigid & Flexible)
• Metal shaft between 24 to 33
cm.
3 important structural differences
in telescope available in the
market:
• No. of the rod lens - 6 to 18 rod
lens system telescopes
• Angle of view: Between 0° & 120°
• Diameter: 1.5 to 15 mm.
Prof. S. Subbiah et al

10. TELESCOPE - ANGLE OF VIEW
Prof. S. Subbiah et al

11. VIDEO MONITORS
• Used to display the image
Monitor size 8 – 21 inches
• Positioned optimally when hung
from the ceiling on light blooms
Prof. S. Subbiah et al

12. INSUFFLATION SYSTEM
• Insufflation pressure can be
continuously varied from 0 to 30
mm Hg
• Total gas flow volumes can be
set to any value in the range 0 to
45 liters/ mm.
• Preset pressure (ideally
12mmHg) not >18mmHg
Prof. S. Subbiah et al

13. INSUFFLATION SYSTEM
• Flow rate >7L/min, risk of
hypothermia to patient.
• To avoid this, Laproflattor -
Electronic heating system which
maintains the temperature of
CO2
• Thoracoscopy: No gas
insufflation.
• In specific cases, (mediastinal
tumor resection, diaphragmatic
surgery) at low pressure (5–
8 mmHg) may be applied
Prof. S. Subbiah et al

14. SUCTION /IRRIGATION
SYSTEM
 Suction irrigation tube -Blunt
dissection.
 10 mm suction tube if there is
>1,500 ml of hemoperitoneum
or if there is blood clots inside
the abdominal cavity.
Prof. S. Subbiah et al

15. VERESS NEEDLE
3 lengths – 80 mm, 100 mm, 120 mm.
• Obese patient 120 mm ; very thin patient
(scaphoid abdomen) 80mm
• Maximum flow rate – 2.5L/min
 Indicators of Safe Veress Needle Insertion
Needle Movement Test
Irrigation Test
Aspiration Test
Hanging Drop Test
Quadro-manometric Test
Prof. S. Subbiah et al

16. • Outer cannula with a beveled needle point.
• Inner stylet, with a spring that “springs
forward” in response to the sudden decrease
in pressure encountered upon crossing the
abdominal wall and entering the peritoneal
cavity
Prof. S. Subbiah et al

17. Quadro- Manometric indicators
Initial pressure, <5 to 6 mm Hg.
Abnormally high pressure (Max- 15 mm Hg) –
Patient not anesthetized adequately
If the insufflator records a pressure of 15 mm Hg,
it can be due to
• Placement into an intra-abdominal organ.
• Needle tip may be against Omentum or in
preperitoneal space.
• Insufflation line occlusion at stopcock or tube
kink
4 readings of insufflator.
 Preset insufflation pressure
 Actual pressure
 Gas flow rate
 Volume of gas consumed.
Prof. S. Subbiah et al

18. Open Access
• Direct entry, without creating
pneumoperitoneum and
insufflator is connected
• Disadvantages: Persistent
uncontrolled CO2 leak, Increased
incision size & Increased time for
placement.
• Various methods
 Hasson’s technique,
Scandinavian technique
 Fielding technique
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20. PORT CHARACTERISTICS
• Bladed trocars cut the
abdominal wall fascia during
entry
• Bladed ports have a shield that
retracts as the blade is pushed
through the fascia of the
abdominal wall, and then it
engages once inside the
abdomen.
Prof. S. Subbiah et al

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22. INSTRUMENTATION
• Length 18–45cm; approximately 36 cm in adult and 28 cm in
Paediatric practice.
• Shorter instruments 18 – 25cm are adapted for cervical and
paediatric surgery
• 45 cm instruments – obese or very tall patients.
• Diameter from 1.8 – 12 mm; Majority 5 to 10 mm of cannula
• Better ergonomics – Half of instrument inside & half outside (behaves
like a class 1 lever)
Prof. S. Subbiah et al

23. INSTRUMENTS (PARTS)
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25. • Tip vibrates at 55500 Hz
generates stress and friction
in tissue, produces heat and
causes protein denaturation.
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26. CLIP APPLICATOR
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27. ELECTRO-SURGICAL INSTRUMENTS- SAFETY
CONSIDERATIONS
Overshooting
Direct coupling
Capacitive coupling
Insulation failure
Prof. S. Subbiah et al

28. Overshooting
Tip of energized instrument
going beyond the field of vision.
Common mistake (beginners)
Trainer should keep a hand on
trainees while inadvertent shoot
Prof. S. Subbiah et al

29. Direct coupling
• The active electrode should not
be in close proximity
• Do not activate the generator
while the active electrode is
touching or in close proximity to
another metal object
Prof. S. Subbiah et al

30. Capacitive coupling
• Ability of two conductors to
transmit electrical flow even if
they are separated by an intact
layer of insulation
• Plastic anchor will prevent the
energy from dissipating and
increase the likelihood of a
thermal burn.
• Surface area is <3 cm2 or the
current density is approximately
7 W/cm2
Prof. S. Subbiah et al

31. Insulation failure
Only 10% of insulated
instrument is visible
67% of such injuries are not
recognized at the time of
surgery.
Perforated bowel, diaphragm,
urinary bladder, permanent
disfigurement, faecal peritonitis
Prof. S. Subbiah et al

32. Port closure
• Port site hernia: 0.02 – 3.6 % &
usually remains unreported
• All defects created >10mm
should be closed
• Port placement lateral to the
rectus muscle
Prof. S. Subbiah et al

33. ERGONOMICS
• Best suiting the worker to his
job, or to make the setting &
surroundings favorable for the
worker. (1949)
• Correct ergonomics can reduce
suturing time
• Pressure-related chronic pain
relieved by the use of
ergonomically designed
products. Prof. S. Subbiah et al

34. • Lack of Tactile Sensation
Lack of tactile feedback & long graspers maneuvered through the trocars
reduce the efficiency & increase the time of dissection.
• Decreased Degree of Freedom of Movement
During laparoscopic surgery, there is a two-dimensional (2D) vision and loss
of depth perception to some extent
Only 4° of freedom (rotation, up/down angulation, left/right angulation,
in/out movement). Falk et al – an increase in the degree from 4 to 6 increases
the dexterity by a factor of 1.5
Prof. S. Subbiah et al

35. • Decoupling of the Visual (Monitor) and Motor Axis
• Loss of depth perception & peripheral vision limit the viewing
spectrum offered.
• Working in separate coordinate systems decreases performance,
leading to higher rates of error in the procedure
• Assumption of Relatively Static Posture
• Static postures - more disabling & harmful than dynamic postures are
since muscles and tendons build up lactic acid and toxins when held
for prolonged periods in same postures.
Prof. S. Subbiah et al

36. Drawbacks for the Surgeon
• Carpal tunnel syndrome,
• Eye strain,
• Cervical spondylosis
• Thenar neuropathy (awkward
thumb grips) in case of
laparoscopic pistol-grip
instruments
Prof. S. Subbiah et al

37. • Sensorial ergonomics
(manipulations and visualization)
improve precision, dexterity, and
confidence.
• Physical ergonomics provide
comfort for surgeon.
• Together, increase safety, better
outcome and reduce the stress
Prof. S. Subbiah et al

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39. Equipment-related Challenges
• Operating field on video screen placed at 4 to 8 feet away from the
surgeon’s eye
• Use of angulated scopes achieve better view of anatomy in difficult
situations. (zero Vs 30° scopes)
• Laparoscopic grasper transmits the force of the surgeon’s hand from
the handle to the tip 1:3 Vs 3:1 ratio with a Hemostat. (six times
harder for similar results)
Prof. S. Subbiah et al

40. DIAMOND BASE BALL CONCEPT
ELEVATION ANGLE:
Angle between the instruments and body of the
patient. (Ideally should be 60 degrees)
Step 1: Find out the target of dissection,
Step 2: Choose the correct length
(Paediatrics: 28 cm; Adult: 36 cm;
Obese: 45 cm)
Step 3: Keep target at centre,
Draw 2 arcs,
1st arc 18cm from the target;
2nd arc 24 cm from the target
Prof. S. Subbiah et al

41. AZIMUTH ANGLE:
Angle between the telescope and
instruments i.e., contralateral port position.
Ideally, 30 degrees (range 15 to 45 degree)
 Linear parallax – Depth perception will be
good
 Relative size – object far will appear to be
small and vice versa
 Aerial gradient – object near will appear to
have better contrast and colour
 Texture gradient – near object appear to have
detailed surface
 Correct shadow – shadowing as the cue for
depth
Prof. S. Subbiah et al

42. • MANIPULATION ANGLE:
Angle between two working hand
instruments should be 60 degrees +/- 15
degree
• Put the tip of the index finger over the target
of dissection
• Put the tip of thumb over the site of
telescope.
• Position of anatomical snuffbox will give a
rough estimation of working port position on
both sides in adults.
Prof. S. Subbiah et al

43. PATIENT POSITIONING
• Safety belt to prevent the sliding
of the table is placed 5cm above
the knee and never over the
abdomen.
• Side supports to prevent lateral
displacement.
• Shoulder supports are used if
the Trendelenburg position is
necessary
Prof. S. Subbiah et al

44. Lloyd-Davies position
• Modification of the lithotomy
position with hips minimally
flexed to around 15° with a 30°
head-down tilt.
• Both legs are simultaneously
placed in the stirrups.
• Fingers should not extend past
the edge of the table
• The legs should not be
externally rotated or unduly
abducted.
• Sequential compression devices
- prevent venous stasis,
Prof. S. Subbiah et al

45. ALLEN STIRRUPS
• Venous and arterial insufficiency
in long procedures
(compartment syndrome, deep
venous thrombosis)
• Digital amputation at the edge
of the bed.
• Hyperflexion – Sciatic nerve
damage.
• Saphenous and peroneal
neuropraxia (Stirrups).
Prof. S. Subbiah et al

46. STERILIZATION
CLEANING
• Removes debris, mucous, blood & tissue -- interfere with
disinfectant.
• Current recommendations specify disassembly of equipment prior to
sterilization
• At least 300 ml of water should be flushed through these instruments
to clean it properly.
• 99.8 % of the bioburden removed by meticulous cleaning
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47. • 2 methods of sterilization
Steam sterilization
Chemical sterilization
• Autoclaving by means of steam was the oldest, safest & most cost-
effective one
• Camera head (CCD) is damaged by chemical sterilization with
repeated exposure. A sterile plastic sleeve or sterile thick cloth sleeve
should be used to avoid contamination
Prof. S. Subbiah et al

48. Ethylene Oxide
• Colorless at ordinary temperatures, odor similar ether and is
extremely toxic and flammable.
• 12 % EtO with 88 % freon - Inflammable
• Low temperature, typically between 49° and 60°C (130–140°F) and
relative humidity of 40 to 60%
• Takes between 3 and 6 hours for the sterilization portion of the cycle
to be completed
Prof. S. Subbiah et al

49. Hydrogen Peroxide Gas Plasma
• Hydrogen peroxide and water (59% nominal peroxide by weight) -
vaporized and allowed to surround and interact with the devices to
be sterilized
• No aeration time is required
• Used immediately or placed on a shelf for later use
Prof. S. Subbiah et al

50. Glutaraldehyde
• 2 % aqueous glutaraldehyde solution is effective liquid chemical
sterilant.
• Item is completely immersed for 10 hours at 25º C in especially
designed tray.
• After immersion, the item must be rinsed thoroughly with sterile
water prior to use
• Should be used maximum 15 times or 21 days after activation,
whichever may be earlier.
Prof. S. Subbiah et al

51. FORMALDEHYDE
• Bactericidal properties
• 37 % aqueous solution (formalin)
or 8 % in 70 % isopropyl alcohol
• Kills microorganisms coagulating
intracellular protein.
• Airtight formalin chambers
• Vapors acts for one week, (after
that – Change)
• 12 to 24 hours to be effective.
Prof. S. Subbiah et al

52. Orthophthalaldehyde
• 0.55 % non-glutaraldehyde solution for disinfection of delicate
instruments
• 2 yrs shelf life and 75 days open-bottle shelf life
• Rapid 5 minutes immersion time at a minimum of 25ºC
• Efficient 12 minutes soak time at room temperature (20° C) for
manual reprocessing
• Effective against glutaraldehyde-resistant mycobacterium
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53. Thank you
Prof. S. Subbiah et al