This document discusses laparoscopic surgery, a minimally invasive procedure that allows access to the peritoneal cavity for operations using small incisions and a laparoscope. It covers the history, instruments, advantages, and complications of laparoscopic procedures, emphasizing the importance of proper instrument handling and decontamination to ensure patient safety. The document also outlines the ergonomics and challenges faced by surgeons during laparoscopic surgeries, including the benefits and drawbacks of robotic-assisted laparoscopic techniques.

1. Disclosure
I have no actual or potential conflict of interest in relation to
this program/presentation
Prof. Dr. Mohammed Shadrul Alam
MBBS, MS, FCPS, FRCS, FACS
Pediatric Urologist & Health Economist
MuMCH

2. What is laparoscopy and its
applications
History
Instruments ( details)
Indications and
contraindications
Physiological changes
Port of laparoscopy
Complications during
operation
Commonly practiced
laparoscopic surgeries
Contents

3. Definition
It is a minimally access procedure allowing
endoscopic access to peritoneal cavity after
insufflation of gas to create space between the
anterior abd. Wall & viscera for safe manipulation
of instruments & organs.

4. What is laparoscopic surgery?
Operation performed in pelvis or abdomen
through small incisions
Done for diagnostic purpose or to perform a
surgery
Small camera called laparoscope is used
Benefits- patients experience less pain,
smaller chance of hemorrhaging, and
shorter recovery time

5. Tools for Standard Laparoscopic Surgery
2 types of laparoscopes:
1) Telescopic rod lens system
-attached to a video camera
2) Digital laparoscope
-fiber optic cable system is
connected to a light source
so operative area can be
illuminated
-then inserted through tiny tube (cannula) to see the
operation
-abdomen is then insufflated with carbon dioxide (not
harmful to body) to raise abdominal wall above organs

6. HISTORY
George Kellingused cystoscope to observe abd organs of dogs—
CYSTOSCOPY
1910 – Swedish physician Hans Christian Jacobaeus used this procedure
in man and coined the term – LAPAROSCOPY
1987 – Mourett in France successfully removed a diseased gall bladder
laparoscopically

7. Introduction
• Laparoscope = thin telescope with light source
• Minimally invasive surgical technique
• Operations in abdomen or pelvic cavity
• Laparoscope inserted 5-10mm canula
• Side port 5-10mm for grasper
• Abdomen insufflated: CO2 or N gas
Details of Laparoscopy:

8. Introduction (cont.)
Why Laparoscopy?
•Minimize blood loss
•Minimize post-operative pain
•Expedite recovery time
•Less risk of complications
•A much smaller scar

9. Endoscopic vs. Laparoscopic Surgery
Endoscopy: An illuminated usually fiber-optic flexible or rigid tubular
instrument for visualizing the interior of a hollow organ or part (as the
bladder or esophagus) for diagnostic or therapeutic purposes that
typically has one or more channels to enable passage of instruments
(as forceps or scissors). Examples: bronchoscopy, cystoscopy.
Laparoscopy:
1: visual examination of the inside of the abdomen by means of a
laparoscope—called also peritoneoscopy
2: an operation (as tubal ligation or gallbladder removal) involving
laparoscopy.
Examples: laparoscopic appendectomy, LAVH.

10.  Smaller incisions
Less likely to suffer wound-related complications.
 Less post-operative pain
 Decreased hospital stay
Some laparoscopic procedures are performed on an
outpatient basis.
 Accelerated recovery and
improved outcome
Advantages of Laparoscopic Procedures

11. Background
Problem at hand:
• Clips restrain tissue from surgical procedure
• High pressure, tissue closest to joint
• Phenomenon: Tissue expelled, trauma caused

12. Design Objective
• Grasping instrument designed for internal use
• Minimize moving parts and safety hazards
• Equalize pressure across length of clip
• Device must be <5mm diameter
Specifications:

13. INSTRUMENTS USED
1. Zero degree laparoscope
2. Cold light source (Halogen and Xenon lamp)
3. Camera ( 3chip camera commonly used with high resolution
4. Video monitor to display images
5. CO2 insuffulator
6. Long fine dissectors
7. Hooks and spatulas with cautery for dissections
8. Clip applicators
9. Needle holders
10. Veress needle
11. Trocars of different sizes – 10mm, 5mm
12. Suction irrigation apparatus
13. Reducers to negotiate smaller instruments through larger
ports

15. Telescope
There are three important structural differences in
telescope available
1. 6 to 18 rod lens system telescopes are available
2. 0 to 120 degree telescopes are available
3. 1.5 mm to 15 mm of telescopes are available

16. Instruments Used in Laparoscopic
Procedures
Trocars and cannula
Insufflators & Veress needle
Light source & light cord
General lap. instrumentation
Laparoscope

17. Trocar & Cannula
 Trocars and cannula are instruments used to access the surgical
site through small incision or puncture holes (an access port).
 They are made in both reusable and disposable varieties.
Stainless Reusable
Trocar System
Yello-Port Reusable
Trocar System

18. Trocar
The trocar has a blade with a shaft and body.
The body includes a pointed tip which makes the initial
incision in the abdominal wall of the patient.
(Trocar diameters range from 2mm-30 mm)
Most common trocer is 5mm & 10mm
Technique
Head end of the table is lowered to have easier insertion of
needle scope
Pressure bandages are applied to both legs to improve the
venous return
Ryle’s tube and foley’s catheter are essential before insertion
of the trocars
Pneumoperitoneum is created using veress needle through
umbilical incision

19. Insufflator
• The insufflator is a device that enables visualization of the internal
surgical area by creation of a pneumoperitoneum.
• This is accomplished through pumping carbon dioxide gas into the
abdomen under pressure through the Veress needle.

20. Laparoscopic Instrument Types
There are dozens of different types of laparoscopic instruments.
We will examine a few of the main
families of laparoscopic instruments

21. Laparoscopic Instrument Types
Traumatic Graspers
Atraumatic Graspers
Teeth

22. Needle Holders
Retractors

24. Light Source
Degree of brightness
Powerswitch
Brightness adjustment
Fibre-opticcable
Department of Surgical
Research and
Techniques
5thPractice
Check the light cable
before use!

25. Telescope (bajonet) joint
Programing /White balance
Focus ring
Zoom ring
Cabeltothecontroller
Department of Surgical Research and
Techniques

31. Patient Safety Begins With Decontamination
Healthcare staff who are responsible
for processing laparoscopes and
associated items can have a
major impact on the risk for surgical
site infections (SSI) during
laparoscopic procedures.
Over 90% of infection outbreaks
related to laparoscopic instruments
can be prevented if processing of
instruments and equipment is
properly conducted.

32. AORN recommends that individuals
handling laparoscopic instruments
should be competent in their care and
handling.
Instruments with lumens are among
the most difficult to decontaminate
effectively.
Decontamination: Care & Handling
Always wear personal protective
equipment and follow standard
precautions.

34. Assembly: Care & Handling
 It is important to remember that
surgical instruments are complex
and fragile.
 Personnel who are responsible for
instrument care should:
•Be cautious when handling
instruments.
•Use all instruments, tools, and
equipment for their intended
purpose only.
•Follow processing protocols
carefully.

36. Inspection: Care & Handling
Laparoscopic instruments should be inspected after use, ALL
instruments in set!
Evaluate equipment’s integrity, function, and cleanliness.
All insulated laparoscopic instruments should be tested with a
current tester every time the set is assembled!
Damaged instruments should removed from service.

37. Equipment failures can compromise
patient safety in several ways. Prior to
use, all laparoscopic instruments must
be tested.
Compromised insulation can cause
internal patient burns. A video example
is shown on the next slide.
Surgeon and scrub tech can be
burned by broken insulation in
instruments.
Cracked insulation can allow
bioburden to become trapped and
instrument sterility is compromised.
Inspection: Insulation Testing
With proper laparoscopic instrument testing each time the
instrument is reprocessed, these burns can be avoided.

39. Spaulding Classification System

40. Care & Cleaning
In order to avoid drying of operation residues and spreading of germs in
the endoscopy areas, the instruments must be placed in a combined
disinfecting and cleaning solution immediately after use.
In connection with this:
 Store optical and mechanical components separately.
 Dismantle instruments.
 Take off rubber and sealing caps.
 Clean thoroughly since blood, pus, protein residues etc. can call subsequent
disinfection or sterilization into question.
 Clean existing inner areas, such as guide channels etc., with the relevant
cleaning brush and swab.
 Rinse open valves and narrow channels with a cleaning gun. Carry out rinsing
and brushing of the channels under the surface of water, to avoid spraying of
germs in the environment.
 Rinse all components first with cold and then with warm water.
 Lay the used instruments carefully in the boxes. The detergent solution must be
appropriate for the disinfectant.
 Lay the instruments in a combined cleaning and disinfecting solution.
 Subsequently rinse with distilled water and then dry inside and out with a cloth,
swab or dry air.

41. Inspection & Functionality
Inspect instruments for functionality and for any damage that has
occurred after each cleaning.
• Replace brittle and cracked sealing caps.
• Oil all moving components sparingly after cleaning with endoscope
oil. Wipe off excess oil with a disposable towel.
• Sparingly grease rotating valves, valve pistons from trocar sleeves
etc. after cleaning (before steam sterilization) with endoscope
grease.
• Inspect the insulation of the cable and connections for cuts, holes,
cracks, blowing, wear, etc. Do not use any damaged instruments.
• Send damaged instruments to the factory for repair.

42. What gas is commonly used to inflate the abdominal
cavity for a laparoscopic procedure?
• Oxygen
• Carbon Dioxide
• Carbon Monoxide
• Nitrous Oxide
What is the medical term for making internal organs
easier to visualize by inserting gas into the
abdominal cavity?
• Pneumoperitoneum
• Pneumothorax
• Pneumonisis
• Indigestion

43. What instruments are used to access the
surgical site through small puncture holes?
a) Trocanter & Cannula
b) Trocar & Candlestick
c) Trocar & Cannula
d) Trocanter & Calendula
What is an advantage of minimally invasive
surgery?
a) Smaller Incision
b) Decreased Hospital Stay
c) Less Pain
d) All of the above

44. What is part of the laparoscopic instrument inspection
process contributes the most to patient safety?
a) Assuring it’s lubricated
b) Checking for faulty insulation
c) Handle feels comfortable
d) Tip protectors are secured
LAVH is an abbreviation for a surgical
procedure. What does the abbreviation
stand for?
a) Look Around Very Hard
b) Lap Assisted Vaginal Hysterectomy
c) Lap Assisted Vaginal Hysteroscopy
d) Laparotomy And Vaginal Hysterectomy

45. CONTRAINDICATIONS
1. Absolute - none
2. Relative
i) severe COAD
ii) recent MI
iii) ventriculoperitoneal shunts
iv) Increased ICT
v) extensive organomegaly
vi) CHF

46. Complications
Insertion Related :
1) Major vascular injury
2) GI Injury
3) Bladder injury
4) CO2 embolism
5) Abdominal wall
haemorrhage
Post Insertional:
1) GI perforations
2) Laceration & bleeding from
solid organs
3) Abdominal wall hernia
Pneumoperitoneal Related:
1) CO2 embolism
2) Hypercarbia
3) Respiratory acidosis
4) Subcutaneous emphysema
5) Renal failure
6) Venous thrombosis
7) Pneumothorax

47. Ergonomics of Laparoscopy
Increased Time/Fatigue
Length of instruments
- Increased Tremor
- Only about 4 Degrees of Freedom compared
to human hands that provide 36 DOF and
mechanical redundancy
Spatial disorientation/ instrument movement
- Fulcrum Effect
Greater force required to grip instruments
Only one size of instruments often available

48. Ergonomics of Laparoscopy
Increased Time/Fatigue*
Reduced ability to sense tissue characteristics
Surgical Fatigue Syndrome
- A four hour performance “wall” that is manifested
by mental exhaustion, irritability, impaired surgical
judgment, and reduced manual dexterity
Visual fatigue
- long term effect is unknown
Possibly significant cardiovascular stress
*D. A. G. Reyes, B. Tang, A. Cuschieri, 2006, Minimal access surgery (MAS)-related
surgeon morbidity syndromes, Surgical Endoscopy, v.20(1), p. 1-13

49. Ergonomics of Laparoscopy
Posture*
Overhead or side placement of monitor
- Ideal placement is to the front, near the hands
There is an increase in the amount of equipment,
which leads to a need to maneuver around them
Stiff upright with little movement
- Less opportunity to shift weight
Requires raised arms placed in awkward positions for
extended periods of time
*D. A. G. Reyes, B. Tang, A. Cuschieri, 2006, Minimal access surgery (MAS)-related
surgeon morbidity syndromes, Surgical Endoscopy, v.20(1), p. 1-13
Berguer R., 1999, Surgery and ergonomics, Archives of Surgery, v.134(9), p. 1011-1016

50. Ergonomics Of NOTES
No tactile response
Visual fatigue
Constant holding of the endoscope
induces fatigue
Endoscopy can lead to musculoskeletal
pain in fingers, wrists and shoulders*
Young Hye Byun, Jun Haeng Lee, Moon Kyung Park, 2008, Procedure-related musculoskeletal
symptoms in gastrointestinal endoscopists in Korea, World J Gastroenterol, v.14(27)

51. Minimally Invasive Surgery:
Robot Assisted

52. Why Robotic Surgery ?
■a 400X magnified 3D high-definition vision with
adequate precision and control
■special wristed instruments that bend and rotate far
greater than the human wrist
■Less blood loss
■Shorter total operating time
■Less need for narcotic pain medicine
■Shorter hospital stay
■Faster return to normal activities

53. ■ Nevertheless, disadvantages to
robotic-assisted laparoscopic surgeries
are
■ no tactile feedback,
■ increased setup time, and
■ cost

65. The Ever Changing Future
A New Endoscopic Microcapsule Robot
using Beetle Inspired Microfibrillar
Adhesives*
* Proceedings of the 2005 IEEE/ASME International Conference on Advanced Intelligent Mechatroni
Monterey, California, USA, 24-28 July, 2005

66. The Ever Changing Future
Nanobots
Operated by Clinician Engineers or
Surgeons?