The document discusses trocar site herniation (TSH), a complication of minimal access surgery where abdominal contents protrude through incisions made for laparoscopic ports. TSH requires emergency repair and can lead to bowel complications if left untreated. The literature recommends preventative measures like fascial closure of port sites ≥10 mm to prevent TSH. Additional risk factors include port location, obesity, extensive port manipulation, and poor port closure technique. Proper closure of fascial defects at port sites is emphasized as the most important preventative factor against TSH. Various port closure instruments and techniques are described, including the use of a Veress needle which allows port closure to be performed internally under vision. Meticulous port closure can
This document provides an overview of basics of laparoscopy in gynecology. It describes the key components and steps of laparoscopy including pneumoperitoneum creation using Veress needle or open technique, trocar placement using safe entry techniques, and use of laparoscopic instruments. It discusses the imaging system including light source, camera, monitor and recording systems. Advantages of laparoscopy over open surgery and indications are highlighted. Potential complications are also reviewed.
This document provides guidelines for laparoscopic entry techniques. It discusses positioning the patient and various methods for primary and secondary port entry. The preferred primary entry is through the umbilicus using a closed Veress needle technique. Guidelines are provided for Veress needle insertion including abdominal pressure, saline testing, and insufflation. Alternatives like Palmer's point or open Hasson technique should be considered if umbilical entry fails or is risky due to adhesions. Secondary ports should be inserted under direct vision at specific locations and angles to avoid injury.
This document discusses trocar issues in laparoscopy. It notes that the initial trocar insertion is the most dangerous step and can result in injuries to the bowel or vasculature in over 50% of cases. It recommends inserting the first trocar at the umbilicus as it has minimal intervening tissue. Away from the midline poses risks of injuring major blood vessels. Direct trocar insertion is an alternative that may decrease operative time compared to Veress needle. However, no single technique is proven safest and complications can occur regardless of approach. Immediate conversion to open surgery is needed if a vascular injury is suspected.
LAPAROSCOPIC INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #laparascopicinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy and Open inguinal hernia repair
• In this video today, I have discussed Laparoscopic Inguinal Hernia Repair- both TAPP and TEP approaches.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Entry technique with veress needle in LaparoscopyDrVarun Raju
The document summarizes the Veress needle technique for establishing pneumoperitoneum during laparoscopic surgery. It describes how Janos Veress first developed the spring-loaded needle in 1932 for tuberculosis treatment. Modern Veress needles are 12-15 cm long and have a blunt inner stylet and sharp outer cannula. Placement is typically at the umbilicus using various tests like aspiration and insufflation pressure to confirm intraperitoneal placement before trocar insertion. Complications can occur if not properly positioned.
1) Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that uses an endoscope passed through natural openings like the mouth, vagina, or anus to perform internal surgery without external incisions.
2) NOTES was first described in animal models in the early 2000s and the first human transgastric cholecystectomy was reported in 2007.
3) While offering advantages over laparoscopy by avoiding external incisions, NOTES faces challenges of developing improved flexible instruments, closing access sites without leaks, and standardizing safe techniques.
This document provides an overview of basics of laparoscopy in gynecology. It describes the key components and steps of laparoscopy including pneumoperitoneum creation using Veress needle or open technique, trocar placement using safe entry techniques, and use of laparoscopic instruments. It discusses the imaging system including light source, camera, monitor and recording systems. Advantages of laparoscopy over open surgery and indications are highlighted. Potential complications are also reviewed.
This document provides guidelines for laparoscopic entry techniques. It discusses positioning the patient and various methods for primary and secondary port entry. The preferred primary entry is through the umbilicus using a closed Veress needle technique. Guidelines are provided for Veress needle insertion including abdominal pressure, saline testing, and insufflation. Alternatives like Palmer's point or open Hasson technique should be considered if umbilical entry fails or is risky due to adhesions. Secondary ports should be inserted under direct vision at specific locations and angles to avoid injury.
This document discusses trocar issues in laparoscopy. It notes that the initial trocar insertion is the most dangerous step and can result in injuries to the bowel or vasculature in over 50% of cases. It recommends inserting the first trocar at the umbilicus as it has minimal intervening tissue. Away from the midline poses risks of injuring major blood vessels. Direct trocar insertion is an alternative that may decrease operative time compared to Veress needle. However, no single technique is proven safest and complications can occur regardless of approach. Immediate conversion to open surgery is needed if a vascular injury is suspected.
LAPAROSCOPIC INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #laparascopicinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy and Open inguinal hernia repair
• In this video today, I have discussed Laparoscopic Inguinal Hernia Repair- both TAPP and TEP approaches.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Entry technique with veress needle in LaparoscopyDrVarun Raju
The document summarizes the Veress needle technique for establishing pneumoperitoneum during laparoscopic surgery. It describes how Janos Veress first developed the spring-loaded needle in 1932 for tuberculosis treatment. Modern Veress needles are 12-15 cm long and have a blunt inner stylet and sharp outer cannula. Placement is typically at the umbilicus using various tests like aspiration and insufflation pressure to confirm intraperitoneal placement before trocar insertion. Complications can occur if not properly positioned.
1) Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that uses an endoscope passed through natural openings like the mouth, vagina, or anus to perform internal surgery without external incisions.
2) NOTES was first described in animal models in the early 2000s and the first human transgastric cholecystectomy was reported in 2007.
3) While offering advantages over laparoscopy by avoiding external incisions, NOTES faces challenges of developing improved flexible instruments, closing access sites without leaks, and standardizing safe techniques.
The document describes surgical procedures for removing kidney stones. It indicates that open surgery is still needed in cases of obstruction, infection, failed lithotripsy, or stones too large for other procedures. It then provides details on instruments, incisions, and techniques for simple pyelolithotomy, coagulum technique, extended pyelolithotomy, and managing stones extending into the ureteropelvic junction. The goal is to remove all stones and debris while minimizing damage to the kidney and ensuring the pelvis can be closed watertight.
Anorectal malformations are a major problem in newborns, occurring in about 1 in 5000 births. They result from abnormalities in the development of the anorectum during the first 9 weeks of pregnancy. Anorectal malformations can be classified based on the location of the blind rectal pouch in relation to the levator ani muscle. Treatment involves surgical correction, which may be done in one or multiple stages depending on the type of malformation. Prognosis is generally good for low anomalies treated with a single surgery, but higher anomalies have a lower chance of achieving absolute continence due to the complexity of the condition.
NOTES (Natural Orifice Transluminal Endoscopic Surgery)- By Dr. Onkardronkarsingh
Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an experimental surgical technique that performs abdominal operations through natural orifices like the mouth, urethra, anus or vagina without external incisions. NOTES aims to reduce surgical trauma and pain for patients by avoiding incisions. It also shortens recovery time and eliminates risks of complications from external incisions like infections and hernias. While still in development, NOTES shows promise as a less invasive future of surgery.
- Laparoscopic repair of recurrent inguinal hernias has low recurrence rates of 0-1.1% and is associated with less pain and faster recovery compared to open repair.
- TEP repair is an effective procedure for treating direct, indirect, pantaloon, and recurrent hernias through small incisions with early return to normal activities and is a reliable technique for recurrent hernia repair after previous endoscopic herniorrhaphy.
- The learning curve for TEP is longer than for open repair, with some studies suggesting surgeons need to perform more than 100-250 laparoscopic procedures before recurrence rates fall below 5%.
This document summarizes the experience with hypospadias repair at a single medical center in Pakistan between 2007-2011. It found that two-stage Bracka repair was the most common procedure (76.2% of cases) due to a relative lack of expertise in single-stage repairs. Post-operative complications included fistula formation (26.6%), edema (28.3%), and infection (4.2%). Fistula rates were higher for residents compared to specialists (33.1% vs 23.3%) and for two-stage versus single-stage repairs (66.9% vs 44.1%). The document recommends increasing expertise in single-stage repairs, revising guidelines to narrow the criteria for
This document provides an overview of laparoscopic instrumentation used in minimally invasive surgery. It discusses the key components needed, including optical devices like telescopes and cameras, equipment for insufflation, trocars and other instruments for accessing the surgical site. A variety of operative instruments are described, such as graspers, dissectors, scissors, and bowel/lung clamps. Energy sources like electrosurgery, ultrasonic devices, and staplers are also covered. The document concludes with a discussion of instruments for tissue approximation and hemostasis, including clip appliers and mechanical staplers, as well as some miscellaneous tools.
1. The document discusses the basics of laparoscopy including the laparoscopic tower setup, ergonomics, port placement, entry techniques, energy devices, and complications.
2. Key aspects of ergonomics include following the straight line principle with the tower, monitor, and instruments, proper table height, and triangulating or sectoring port placement depending on whether the surgeon stands ipsilateral or contralateral.
3. Safe entry techniques include closed insertion with a Veress needle or open insertion with direct trocar placement, with Palmer's point being an alternative to umbilical entry.
This document discusses the history and techniques of vaginal hysterectomy. It provides details on the procedure including patient positioning, instrumentation, surgical steps like incising the vaginal mucosa and entering the pelvic spaces, clamping and suturing of ligaments, and uterine removal. Post-operative complications are also reviewed. The document serves as a reference for gynecologists performing this common gynecological surgery.
Baseball diamond concept for port position in laparoscopyJibran Mohsin
1) The document proposes the "Baseball Diamond Concept" for optimal port placement in laparoscopy, with three main principles: the primary port and working ports should be placed with half the instrument inside and half outside the abdomen; the primary port should be positioned between the working ports to allow for depth perception; and the manipulation angle between working instruments should be approximately 60 degrees.
2) It explains the rationales for each principle, including lever mechanics, elevation angles, avoidance of direct coupling between instruments and ports, and optimal depth perception with a contralateral primary port position.
3) Guidelines are provided for measuring and applying the concepts based on the target of dissection and average instrument lengths and hand sizes.
This document discusses various laparoscopy equipment used in minimally invasive surgeries. It describes key components like laparoscopes, trocars, insufflators, and various surgical instruments. A laparoscopic surgeon needs to be technically proficient in operating the equipment and understanding the principles of the instruments being used, as the procedures are technologically dependent and any emergency requires quick problem-solving skills without overreliance on technical support.
This document provides information on operative hysteroscopy, including prerequisites, contraindications, instrumentation, anaesthesia, distension media, indications, and techniques for various procedures like endometrial ablation, uterine septum resection, myomectomy, and adhesiolysis. It discusses the advantages and disadvantages of hysteroscopic morcellators. Complications of hysteroscopic myomectomy and post-operative care are also outlined. Various classifications for submucous fibroids and intrauterine adhesions are presented.
The document discusses caesarean scar defects, also known as uterine niches. It provides information on the prevalence, risk factors, clinical presentation, diagnosis, and management of this condition. Uterine niches are common, affecting up to 70% of those with a prior c-section, and are usually asymptomatic but can sometimes cause bleeding, pain, or infertility. Diagnosis involves ultrasound imaging to identify a triangular defect in the uterine scar with decreased or absent underlying muscle. Larger niches with less residual muscle are more likely to be symptomatic.
1. The document discusses the history and evolution of energy sources used in laparoscopic surgery, from early monopolar electrocautery to newer bipolar and ultrasonic devices.
2. It describes several modern energy devices including Ligasure, Gyrus/Plasmacision, Enseal, Harmonic Scalpel, and Thunderbeat, comparing their features such as vessel sealing ability, thermal spread, and cost effectiveness.
3. The document emphasizes choosing the right energy device for each procedure to ensure the best surgical outcome, and advertises an upcoming endoscopy fellowship program by IAGES for training on various laparoscopic energy sources.
Transgastric and transvaginal endoscopic cholecystectomy procedures were performed in 27 patients between 2007-2008. The procedures were performed using hybrid NOTES techniques, with laparoscopic assistance. Both transgastric and transvaginal routes were utilized to access the peritoneal cavity. The authors present their initial experience with these novel natural orifice techniques for cholecystectomy in humans.
This document discusses injuries to the ureter during gynecological surgeries. It provides details on the surgical anatomy of the ureter, risk factors for injury, common sites of injury, grading of injuries, prevention strategies and intraoperative diagnosis. The key points are:
1. The ureter's course makes it susceptible to injury during pelvic surgeries, especially at the pelvic brim.
2. Injuries occur in 0.3-1% of cases and are most common during hysterectomy.
3. Risk factors include large fibroids, adhesions, and prior pelvic surgery.
4. Prevention relies on proper surgical technique including identification and
It has not changed the nature of disease
The basic principles of good surgery still apply,including appropriate case selection, excellent exposure,adequate retraction and a high level technical expertise
If a procedure makes no sense with conventional access, it will make no sense with a minimal access approach
The cleaner and gentler the act of operation, the less the patient suffers, the smoother and quicker his convalescence,the more exquisite his healed wound.
We actually do not know what is there stored for us, but we believe that laparoscopy is trending towards advancement and nano and robotic technology is going to replace in future.
3D cameras have come into existence and various newer technologies are being invented.
The document discusses complications that can occur during and after laparoscopic surgeries. Some common complications discussed include:
1. Anaesthetic complications such as inadequate muscle relaxation during the procedure, hyperventilation prior to surgery, and possible air embolism from carbon dioxide used for pneumoperitoneum.
2. Complications due to pneumoperitoneum such as respiratory acidosis, increased pressure on veins, and possible effects on renal function from increased abdominal pressure.
3. Surgical complications such as injuries to organs like the stomach, bowel, bladder from trocars or instruments. Thermal injuries from diathermy are also discussed.
4. Other complications mentioned include bleeding, infections, inc
Laparoscopic cholecystectomy is the gold standard for the treatment of gallstone disease. The operation is routinely performed using four or three ports of entry into the abdomen. At laparoscopy hospital, we frequently perform cholecystectomy by two-port method using modified extracorporeal knot.
Minimal access surgery (MAS) a new surgical and
interventional approach, was called by different name and
one of the popular is minimally invasive surgery. However,
unique complications are associated with gaining access
to the abdomen for laparoscopic surgery. The technique
of first entry inside the human body with telescope and
instruments is called access technique. The hallmark of the
new approaches is the reduction in the trauma of access.
The technique for access to the peritoneal cavity, choice of
access technique, placement locations, and port placement
is very important in MAS. Technique of access is different for
different minimal access surgical procedures. Thoracoscopy,
retroperitoneoscopy, axilloscopy, and arthroscopy all have
different ways of access. In this chapter, we will discuss
various abdominal access techniques.
It is important to know that approximately 20% of
laparoscopic complications are caused at the time of initial
access. Developing access skill is one of the important
achievements for the surgeon practicing MAS. First entry or
access in laparoscopy is of two types: (1) closed access and
(2) open access.
The document describes surgical procedures for removing kidney stones. It indicates that open surgery is still needed in cases of obstruction, infection, failed lithotripsy, or stones too large for other procedures. It then provides details on instruments, incisions, and techniques for simple pyelolithotomy, coagulum technique, extended pyelolithotomy, and managing stones extending into the ureteropelvic junction. The goal is to remove all stones and debris while minimizing damage to the kidney and ensuring the pelvis can be closed watertight.
Anorectal malformations are a major problem in newborns, occurring in about 1 in 5000 births. They result from abnormalities in the development of the anorectum during the first 9 weeks of pregnancy. Anorectal malformations can be classified based on the location of the blind rectal pouch in relation to the levator ani muscle. Treatment involves surgical correction, which may be done in one or multiple stages depending on the type of malformation. Prognosis is generally good for low anomalies treated with a single surgery, but higher anomalies have a lower chance of achieving absolute continence due to the complexity of the condition.
NOTES (Natural Orifice Transluminal Endoscopic Surgery)- By Dr. Onkardronkarsingh
Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an experimental surgical technique that performs abdominal operations through natural orifices like the mouth, urethra, anus or vagina without external incisions. NOTES aims to reduce surgical trauma and pain for patients by avoiding incisions. It also shortens recovery time and eliminates risks of complications from external incisions like infections and hernias. While still in development, NOTES shows promise as a less invasive future of surgery.
- Laparoscopic repair of recurrent inguinal hernias has low recurrence rates of 0-1.1% and is associated with less pain and faster recovery compared to open repair.
- TEP repair is an effective procedure for treating direct, indirect, pantaloon, and recurrent hernias through small incisions with early return to normal activities and is a reliable technique for recurrent hernia repair after previous endoscopic herniorrhaphy.
- The learning curve for TEP is longer than for open repair, with some studies suggesting surgeons need to perform more than 100-250 laparoscopic procedures before recurrence rates fall below 5%.
This document summarizes the experience with hypospadias repair at a single medical center in Pakistan between 2007-2011. It found that two-stage Bracka repair was the most common procedure (76.2% of cases) due to a relative lack of expertise in single-stage repairs. Post-operative complications included fistula formation (26.6%), edema (28.3%), and infection (4.2%). Fistula rates were higher for residents compared to specialists (33.1% vs 23.3%) and for two-stage versus single-stage repairs (66.9% vs 44.1%). The document recommends increasing expertise in single-stage repairs, revising guidelines to narrow the criteria for
This document provides an overview of laparoscopic instrumentation used in minimally invasive surgery. It discusses the key components needed, including optical devices like telescopes and cameras, equipment for insufflation, trocars and other instruments for accessing the surgical site. A variety of operative instruments are described, such as graspers, dissectors, scissors, and bowel/lung clamps. Energy sources like electrosurgery, ultrasonic devices, and staplers are also covered. The document concludes with a discussion of instruments for tissue approximation and hemostasis, including clip appliers and mechanical staplers, as well as some miscellaneous tools.
1. The document discusses the basics of laparoscopy including the laparoscopic tower setup, ergonomics, port placement, entry techniques, energy devices, and complications.
2. Key aspects of ergonomics include following the straight line principle with the tower, monitor, and instruments, proper table height, and triangulating or sectoring port placement depending on whether the surgeon stands ipsilateral or contralateral.
3. Safe entry techniques include closed insertion with a Veress needle or open insertion with direct trocar placement, with Palmer's point being an alternative to umbilical entry.
This document discusses the history and techniques of vaginal hysterectomy. It provides details on the procedure including patient positioning, instrumentation, surgical steps like incising the vaginal mucosa and entering the pelvic spaces, clamping and suturing of ligaments, and uterine removal. Post-operative complications are also reviewed. The document serves as a reference for gynecologists performing this common gynecological surgery.
Baseball diamond concept for port position in laparoscopyJibran Mohsin
1) The document proposes the "Baseball Diamond Concept" for optimal port placement in laparoscopy, with three main principles: the primary port and working ports should be placed with half the instrument inside and half outside the abdomen; the primary port should be positioned between the working ports to allow for depth perception; and the manipulation angle between working instruments should be approximately 60 degrees.
2) It explains the rationales for each principle, including lever mechanics, elevation angles, avoidance of direct coupling between instruments and ports, and optimal depth perception with a contralateral primary port position.
3) Guidelines are provided for measuring and applying the concepts based on the target of dissection and average instrument lengths and hand sizes.
This document discusses various laparoscopy equipment used in minimally invasive surgeries. It describes key components like laparoscopes, trocars, insufflators, and various surgical instruments. A laparoscopic surgeon needs to be technically proficient in operating the equipment and understanding the principles of the instruments being used, as the procedures are technologically dependent and any emergency requires quick problem-solving skills without overreliance on technical support.
This document provides information on operative hysteroscopy, including prerequisites, contraindications, instrumentation, anaesthesia, distension media, indications, and techniques for various procedures like endometrial ablation, uterine septum resection, myomectomy, and adhesiolysis. It discusses the advantages and disadvantages of hysteroscopic morcellators. Complications of hysteroscopic myomectomy and post-operative care are also outlined. Various classifications for submucous fibroids and intrauterine adhesions are presented.
The document discusses caesarean scar defects, also known as uterine niches. It provides information on the prevalence, risk factors, clinical presentation, diagnosis, and management of this condition. Uterine niches are common, affecting up to 70% of those with a prior c-section, and are usually asymptomatic but can sometimes cause bleeding, pain, or infertility. Diagnosis involves ultrasound imaging to identify a triangular defect in the uterine scar with decreased or absent underlying muscle. Larger niches with less residual muscle are more likely to be symptomatic.
1. The document discusses the history and evolution of energy sources used in laparoscopic surgery, from early monopolar electrocautery to newer bipolar and ultrasonic devices.
2. It describes several modern energy devices including Ligasure, Gyrus/Plasmacision, Enseal, Harmonic Scalpel, and Thunderbeat, comparing their features such as vessel sealing ability, thermal spread, and cost effectiveness.
3. The document emphasizes choosing the right energy device for each procedure to ensure the best surgical outcome, and advertises an upcoming endoscopy fellowship program by IAGES for training on various laparoscopic energy sources.
Transgastric and transvaginal endoscopic cholecystectomy procedures were performed in 27 patients between 2007-2008. The procedures were performed using hybrid NOTES techniques, with laparoscopic assistance. Both transgastric and transvaginal routes were utilized to access the peritoneal cavity. The authors present their initial experience with these novel natural orifice techniques for cholecystectomy in humans.
This document discusses injuries to the ureter during gynecological surgeries. It provides details on the surgical anatomy of the ureter, risk factors for injury, common sites of injury, grading of injuries, prevention strategies and intraoperative diagnosis. The key points are:
1. The ureter's course makes it susceptible to injury during pelvic surgeries, especially at the pelvic brim.
2. Injuries occur in 0.3-1% of cases and are most common during hysterectomy.
3. Risk factors include large fibroids, adhesions, and prior pelvic surgery.
4. Prevention relies on proper surgical technique including identification and
It has not changed the nature of disease
The basic principles of good surgery still apply,including appropriate case selection, excellent exposure,adequate retraction and a high level technical expertise
If a procedure makes no sense with conventional access, it will make no sense with a minimal access approach
The cleaner and gentler the act of operation, the less the patient suffers, the smoother and quicker his convalescence,the more exquisite his healed wound.
We actually do not know what is there stored for us, but we believe that laparoscopy is trending towards advancement and nano and robotic technology is going to replace in future.
3D cameras have come into existence and various newer technologies are being invented.
The document discusses complications that can occur during and after laparoscopic surgeries. Some common complications discussed include:
1. Anaesthetic complications such as inadequate muscle relaxation during the procedure, hyperventilation prior to surgery, and possible air embolism from carbon dioxide used for pneumoperitoneum.
2. Complications due to pneumoperitoneum such as respiratory acidosis, increased pressure on veins, and possible effects on renal function from increased abdominal pressure.
3. Surgical complications such as injuries to organs like the stomach, bowel, bladder from trocars or instruments. Thermal injuries from diathermy are also discussed.
4. Other complications mentioned include bleeding, infections, inc
Laparoscopic cholecystectomy is the gold standard for the treatment of gallstone disease. The operation is routinely performed using four or three ports of entry into the abdomen. At laparoscopy hospital, we frequently perform cholecystectomy by two-port method using modified extracorporeal knot.
Minimal access surgery (MAS) a new surgical and
interventional approach, was called by different name and
one of the popular is minimally invasive surgery. However,
unique complications are associated with gaining access
to the abdomen for laparoscopic surgery. The technique
of first entry inside the human body with telescope and
instruments is called access technique. The hallmark of the
new approaches is the reduction in the trauma of access.
The technique for access to the peritoneal cavity, choice of
access technique, placement locations, and port placement
is very important in MAS. Technique of access is different for
different minimal access surgical procedures. Thoracoscopy,
retroperitoneoscopy, axilloscopy, and arthroscopy all have
different ways of access. In this chapter, we will discuss
various abdominal access techniques.
It is important to know that approximately 20% of
laparoscopic complications are caused at the time of initial
access. Developing access skill is one of the important
achievements for the surgeon practicing MAS. First entry or
access in laparoscopy is of two types: (1) closed access and
(2) open access.
World's Most Popular Hands-On Laparoscopic Training Instituteraja766604
World Laparoscopy Hospital is a well-known and highly respected international training center for laparoscopic surgery. It offers a comprehensive laparoscopic surgery training course for general surgeons, gynecologists, and urologists. The training program is designed to provide both basic and advanced theoretical and practical experience to the candidates.
The laparoscopic surgery training course at World Laparoscopy Hospital is completely candidate-centered, with an emphasis on practical laparoscopic surgical problems encountered while operating on patients. The training takes place within an ultramodern laparoscopic HD wet operating room, followed by live exposure of live laparoscopic surgery in the operation theater with expert consultants.
The laparoscopic training program is affiliated with a Government-recognized university, and upon completion of the course, candidates receive a Laparoscopic Fellowship and Diploma Certificate issued by a UGC recognized university and the World Association of Laparoscopic Surgeons.
https://www.laparoscopyhospital.com/SERV01.HTM
Minimal access surgery (MAS) a new surgical and interventional approach, was called by different name and one of the popular is minimally invasive surgery. However,unique complications are associated.
Vascular closure devices were developed in the 1990s as alternatives to manual compression for achieving hemostasis after a cardiac catheterization procedure. There are two main types - passive devices that enhance clotting without achieving prompt hemostasis, and active devices that achieve hemostasis more quickly through mechanical or chemical means. Examples of active devices discussed include the Angio-Seal device which uses an absorbable anchor and collagen plug, and the Perclose device which uses an automated suturing mechanism. Studies have shown that active devices can reduce time to hemostasis, ambulation, and discharge compared to manual compression, though they may increase risks of infection and limb ischemia in some cases. Complications associated with vascular closure include bleeding
This presentation is about surgical drains and the techniques of draining the surgical wounds. Advancements in the surgical drains are also discussed and mentioned.
The document discusses surgical drains, including their classification as open or closed, active or passive. It covers advantages and disadvantages of drains, as well as ideal characteristics. Guidelines are provided around placement, monitoring, and removal of drains. Recent advancements include one-way valves, bottom drainage ports, and coatings to reduce tissue trauma. While drains can help detect complications, evidence for their routine use is limited and they may increase risks like infection or induce leaks. Surgeons should carefully consider the purpose and type of drain needed as well as removal timing for each case.
Principles of Laparoscopic Surgery and SAFE Cholecystectomy.pptxAkshaySarraf1
This document provides information on laparoscopic surgery presented by Dr. Akshay Sarraf. It defines laparoscopic surgery and lists its advantages over traditional open surgery such as less pain, shorter hospital stays, and faster recovery times. The document discusses the principles, setup, instruments, and techniques used in laparoscopic surgery including maintaining pneumoperitoneum and port placement. It specifically addresses laparoscopic cholecystectomy as the gold standard procedure for gallbladder removal and emphasizes the importance of safely dissecting Calot's triangle.
This document discusses vascular closure devices (VCDs) that are used to achieve hemostasis after a cardiac catheterization procedure. It covers:
- The goals of VCDs including reducing time to hemostasis, bleeding, and allowing early patient ambulation.
- Types of VCDs including passive devices that augment natural clotting and active devices that mechanically close the artery.
- Examples of specific passive and active devices like Angioseal, Exoseal, and Manta.
- Studies showing VCDs reduce time to hemostasis and ambulation compared to manual compression.
- Tips for proper use of VCDs and potential complications.
The document discusses various vascular closure devices (VCDs), including:
1. Plug-based devices like Angio-Seal, Exoseal, and MynxGrip that use anchors, plugs, or polymers to seal the puncture site.
2. Suture-mediated devices like Perclose Proglide and Prostar that deploy sutures before sheath removal to close the arteriotomy.
3. Mechanical devices like StarClose that use clips, and compressive devices like Catalyst III that use disks, to facilitate hemostasis.
While VCDs can reduce time to hemostasis and ambulation compared to manual compression, meta-
1) The document reviews various incision and closure techniques used in obstetrics and gynecology, including transverse (e.g. Pfannenstiel), vertical (e.g. midline), and laparoscopic incisions.
2) It discusses factors to consider when selecting an incision such as patient characteristics, pathology, and risk of adhesions or malignancy. It also reviews various suturing and closure methods like continuous versus interrupted sutures.
3) The ideal closure method provides good approximation with minimal risk of complications like infection, hemorrhage or wound dehiscence while allowing for the best cosmetic outcome. Layered versus mass closure techniques are evaluated.
1. Video-assisted thoracoscopic surgery (VATS) is a minimally invasive procedure used to diagnose and treat illnesses of the lungs and chest cavity.
2. VATS involves making small incisions and inserting surgical instruments and a camera to allow the surgeon to see inside the chest. This avoids the need for large incisions.
3. VATS is used for procedures like lung biopsies, removal of parts of the lung, treatment of collapsed lungs, and draining fluid from the chest cavity. It offers benefits like less pain, shorter recovery time, and smaller scars compared to traditional open chest surgery.
This document discusses ventral incisional hernia repair and compares the sublay retromuscular technique using lightweight Vypro mesh versus heavier Prolene mesh. It provides background on incisional hernias, risk factors, techniques for open repair including suture repair, inlay, onlay, and sublay/retromuscular approaches. The study aims to evaluate the challenge of the sublay technique with new technical points to reduce recurrence and compare results of Vypro versus Prolene mesh in postoperative complications, chronic pain, and recurrence rates.
The Obstetric Gynaecologis - 2013 - Stavroulis - Methods for specimen remov...Amer Raza
This document discusses different methods for removing specimens from the peritoneal cavity after laparoscopic excision. It describes using mini laparotomy, transumbilical or ancillary port-site incisions, or posterior colpotomy. Recently, using morcellators and endoscopic bags to remove specimens laparoscopically has grown in popularity. The size, whether cystic or solid, and risk of malignancy influence the retrieval method. There is a risk of spillage, especially with suspected early malignancy, so this must be considered during excision and retrieval. In the future, natural orifice transluminal endoscopy may be an operative and retrieval route.
This document describes the mini-open transforaminal lumbar interbody fusion (TLIF) technique. Key points include:
1. Mini-open TLIF provides the benefits of TLIF with less soft tissue disruption through a smaller incision and muscle splitting approach.
2. The technique involves facetectomy, bilateral decompression if needed, interbody cage insertion, and percutaneous pedicle screw fixation through tubular retractors.
3. Advantages over open TLIF include less blood loss, reduced postoperative pain, and shorter hospital stay. However, it requires microsurgical skills and has a steep learning curve.
The Obstetric Gynaecologis - 2014 - Minas - Urinary tract injuries in lapar...Amer Raza
This document discusses urinary tract injuries that can occur during laparoscopic gynecological surgery. It notes that bladder injury is the most common major complication. Prevention strategies include catheterization before trocar insertion, using caution during dissection near the bladder, and adhering to safe electrosurgery practices. Injuries may be recognized intraoperatively through direct visualization, cystoscopy, or detecting urine in trocar ports. Postoperative injuries present with symptoms like pain, hematuria, or oliguria and are diagnosed through imaging or cystoscopy. Most injuries can be repaired laparoscopically by suturing in one or two layers.
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Basics of laproscopic surgery..
by dr navdeep s kamboj presented at sgrdumsar amritsar.
topics covered--
1 basics of laparoscopy
2 lap cholecystectomy
3 lap appendixcectomy
pneumoperitonem
merits and demerits of laproscopy
ligasure
endoscopy,
laparoscopic instruments
Similar to Laparoscopic Port Closure Technique (20)
Ureteral injury is one of the most serious complications of gynecologic surgery. Ureteral injury during laparoscopic surgery has become more common as a result of the increased number of laparoscopic hysterectomies and retroperitoneal procedures that are being performed.
One of the limitations of minimal access surgery is difficulty in retrieval of tissue. Previously, surgeons were reluctant to perform many of the advanced surgical procedure due to this difficult procedure.
On July 11, 2000, the Food and Drug Administration (FDA) approved the first completely robotic surgery device, the da Vinci surgical system from Intuitive Surgical (Mountain View, CA).
Since the advent of laparoscopic surgery in the 1980s, laparoscopic surgery has been popularized by surgeons throughout the world. However, routine laparoscopic surgery has been slow to catch the pregnant patient.
Laparoscopic sterilization was the first popular minimal access surgical procedure ever performed. Laparoscopic sterilization is very straightforward procedure. Worldwide laparoscopic sterilization is now the most commonly applied method for family planning
The esophageal hiatus is an elliptical opening in the diaphragmatic muscular portion. The crura of diaphragm originate from the anterior surface of the first four lumbar vertebrae on the right and L2–L3 on the left to insert anteriorly into the transverse ligament of the central portion of diaphragm.
Laparoscopic ovarian surgery can be used to manage most ovarian abnormalities. Key steps in laparoscopic ovarian cystectomy include aspirating cyst contents, stripping the cyst capsule from the ovarian cortex, and extracting the capsule. It is important to avoid injury to nearby structures like the ureter and completely remove the cyst to evaluate for early carcinoma. Outcomes are better when the ovary can be preserved through cystectomy rather than full oophorectomy. Teratomas require especially careful removal of all contents to prevent chemical peritonitis.
When widespread use of laparoscopy and thoracoscopy in adult patients occurred in the first part of the 1990s, it did not transfer into widespread application in the pediatric population for a number of reasons.
The indications and preparation for laparoscopic liver surgery remain the same as in open hepatic surgery. Visualization is excellent with the laparoscope, and the addition of laparoscopic ultrasound has been shown to help intraoperative plans in 66% of cases when compared to laparoscopic exploration alone.
Gastroesophageal reflux disease (GERD) is defined as the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus. It is a condition which develops when the reflux of stomach contents causes troublesome symptoms and complications.
It is well-known that laparoscopy is the consequence of advances made in the field of medical engineering. Each surgical specialty has different requirement of instruments. Laparoscopy was initially criticized owing to the cost of specialized instruments and possible complications due to these sharp long instruments.
Laparoscopic hysterectomy is a minimally invasive surgical procedure to remove the uterus through small incisions in the abdomen using laparoscopic instruments and visualization. There are several types of laparoscopic hysterectomy depending on the extent of the procedure and whether it is assisted vaginally. Key advantages over traditional abdominal hysterectomy include less postoperative pain, shorter hospital stay, and faster recovery time. Important anatomical structures like the ureters must be carefully identified and protected during the procedure.
Dissection is defined as the separation of tissues with hemostasis. It consists of a sensory visual and tactile component, an access component involving tissue manipulation, and instrument maneuverability.
Laparoscopic exploration of the common bile duct (CBD) is performed either for the diagnosis or the treatment of CBD stones. CBD stones demonstrated by laparoscopic intraoperative cholangiography (IOC) or laparoscopic ultrasonography (LUS) are extracted either through the cystic duct or through choledochotomy.
Laparoscopic colon resections are being performed with increasing frequency all over the world. However, the use of minimal access surgery in colorectal surgery has lagged behind its application in other surgical fields.
Appendicitis was first recognized as a disease entity in the 16th century and was called perityphlitis. McBurney first described its clinical findings in 1889.
TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd...Donc Test
TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Chapters Download Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Download Stuvia Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Study Guide Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Ebook Download Stuvia Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Questions and Answers Quizlet Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Studocu Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Quizlet Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Chapters Download Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Download Course Hero Community and Public Health Nursing: Evidence for Practice 3rd Edition Answers Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Ebook Download Course hero Community and Public Health Nursing: Evidence for Practice 3rd Edition Questions and Answers Community and Public Health Nursing: Evidence for Practice 3rd Edition Studocu Community and Public Health Nursing: Evidence for Practice 3rd Edition Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Pdf Chapters Download Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Pdf Download Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Study Guide Questions and Answers Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Ebook Download Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Questions Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Studocu Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Stuvia
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
LOOPS in orthodontics t loop bull loop vertical loop mushroom loop stop loop
Laparoscopic Port Closure Technique
1. INTRODUCTION
Minimal access surgery is a routine surgical practice due
to its minimal invasive and associated advantages. It has a
lot of advantages but not devoid of complication, one of the
major concerned complication is the trocar site herniation
(TSH). TSH is a serious complication often requiring
emergency repair. If unattended, TSH can lead to small
bowel strangulation and incarceration.
The literature says that preventative measures should
be taken to avoid the occurrence of herniation at the portal
site. Fascial closure has been recommended as a means of
TSH prevention. One study reported a statistically higher
frequency of hernia at 12 mm port site where the fascia was
left open (8%) compared with those that were closed (0.22%)
following laparoscopy. There is a consensus that all the
port site ≥10 mm should be closed due to an increased risk
of herniation. For smaller ports, fascial closure may not be
necessary, except when manipulated extensively.
Trocar site herniation is also associated with other
technical factors other than the port site. Port location is
another factor. There are many reports suggesting that
umbilical sites are at greater risk of herniation when
compared to lateral port sites. This is due to weakness
of the fascia and absence of supporting muscle in the
area. Stretching or even extending the incision of a
port site during specimen extraction has a great risk
hernia development. Factors such as high body mass
index (BMI) are patient-related risk factors that are
associated with TSH. Here it is related to increase intra-
abdominal pressure and increase abdominal wall thickness.
Studies show that wound infection is a predisposing factor
to hernia development. Therefore, closure of fascia is
necessary for umbilical ports, ports sites that are stretched
or enlarged for specimen retrieval, and trocar sites in obese
patients.
Minimally invasive laparoscopic surgery has
revolutionized the way surgery is performed for an
increasing number of patients. Incisional hernia can occur
after any abdominal surgery and laparoscopic surgery is
not immune to this complication. The hernia that follows
laparoscopy usually occurs through the larger ports (size
>10 mm), especially the umbilicus. Fig. 1: Typical port closure needle.
Laparoscopic Port
ClosureTechnique
Predisposing factors include:
■ Previous laparoscopies
■ Extensive manipulation during surgery
■ Increased intra-abdominal pressure
■ Obesity
■ Use of sharp cutting-tip trocars
■ Rapid abdominal deflation at the end of surgery
■ Poor port removal techniques and defective closure of
the abdominal fascia
■ Wound extension
■ Male sex
■ Infection of the wound
■ Pre-existing umbilical defects
■ Postoperative chest infections
■ Pre-existing diseases such as diabetes mellitus
■ Connective tissue disorders
■ Job profile of the patient (weight lifting).
Among all these factors, the single most important factor
remains the improper closure of the fascial defects at the
port sites and not using proper port closure instruments
(Figs. 1 to 3). The diagnosis is often delayed because most
cases present late, and treatment might be instituted along
other lines. Computed tomography scans are helpful in its
diagnosis and will facilitate prompt treatment to avoid the
grave consequence of bowel gangrene.
Prof. Dr. R. K. Mishra
2. 166 SECTION 1: Essentials of Laparoscopy
Fig. 2: Laparoscopic port closure Cobbler’s needle. Fig. 3: Incisional hernia development due to improper closure of
port should be repaired later by mesh.
Fig. 4: The tip of telescope should be introduced in and cannula is
pulled over telescope to prevent suction of omentum or bowel.
While surgical techniques and instrumentation have
made significant advances, it is usual that the surgical
incision is closed using invasive suturing techniques or
by the use of tapes or by the use of topical cyanoacrylate
skin adhesives (TCAs) for closure of surgical wounds. The
incidence of incisional hernia occurring at the port sites after
laparoscopic surgery lies between 0.02 and 3.6% and usually
remainsunreported,untilthedevelopmentofcomplications.
Any port closure technique should have following
characteristics:
■ Effective (strong and secure) surgical wound closure
■ Faster wound closure
■ Better scar cosmesis
■ Occlusive microbial wound dressing
■ Less tissue trauma, reduced inflammatory reaction
■ No requirement for suture/staple removal
■ Easy to use/simple learning curve
■ Reduced risk of needlestick injury—safety and costs
■ Cost effective.
WITHDRAWAL OF INSTRUMENTS AND PORTS
Once the surgery is finished, all the instruments should
be removed carefully under vision. All the accessory ports
should be removed and the gas is removed by releasing the
valve of 10 mm cannulas. The primary port should be taken
out in the end (Fig. 4).
If last port is suddenly withdrawn, sudden suction effect
of cannula can pull the omentum or bowel inside the port
wound, the chance of port-site hernia and adhesion is much
higher in this case. It is a good practice to insert some blunt
instrument or telescope inside the abdomen while removing
the last cannula out over that instrument, to prevent
inadvertent entrapment of omentum or bowel.
The access technique will result in breach in continuity
of abdominal wall which need to be repaired at the end of
surgery. All the 10 mm or >10 mm port should be repaired
properly to prevent any future possibility of hernia. The
rectus sheath should be sutured with Vicryl. Only one stitch
is required in middle which will convert 10 mm wound into
5 mm. The 5 mm port wounds are not necessary to repair.
Laparoscopic Port Closure Instruments
Various types of port closure instruments are available. The
suture passer is a convenient instrument for port closure.
It is used to pass the thread on the side of cannula and then it
is tied externally (Figs. 5A to D).
Port Closure Needle
This is a simple instrument just like cobblers and it can be
effectively used for closing the port. The tip of the instrument
isbluntandtheneedlefacestowardthefascia,sothechances
of injury to the bowel are less with the use of this instrument
(Fig. 6).
3. 167
CHAPTER 12: Laparoscopic Port Closure Technique
C
A B
D
Figs. 5A to D: Port closure with the help of suture passer.
Fig. 6: Port closure needle. Fig. 7: Aneurysm needle.
Aneurysm needle can also be used for closing fascia.
The advantage of this needle is that eye is at the tip and due
to rigid structure there is no risk of bending or rotation of
needle (Fig. 7).
After closing the rectus sheath, the skin can be closed
by intradermal, skin stapler or any of the surgical skin glues
TCAs available (Fig. 8).
New Laparoscopic Port Closure Instruments
Weck®
EFx Shield Fascial Closure
System (Figs. 9A and B)
The Weck®
EFx Shield Fascial Closure System from Teleflex
is the only shielded port closure device, providing enhanced
sharps protection for uniform and consistent performance.
4. 168 SECTION 1: Essentials of Laparoscopy
Fig. 8: Closure of skin wound by skin stapler.
A B
Figs. 9A and B: Weck®
EFx Shield Fascial Closure System.
Figs. 10A and B: NeatClose automated port closure device.
B
A
The EFx Shield®
System is designed with speed and safety in
mind. An array of enhanced features includes:
■ Unique shielded wing design for enhanced sharps
protection
■ Intuitive wing deployment
■ Innovative suture retrieval system for unassisted fascial
closure.
NeatClose Automated Port Closure
Device (Figs. 10A and B)
NeatStitch of Israel has come up with an automated port
closure device known as NeatClose, where it also picked
up both the Food and Drug Administration (FDA) and
European approvals in the process. It is marketed to be an
alternative to manual port closure, making it a speedy and
efficient manner to help laparoscopic surgeon save time
and money by lowering intraoperative costs. This system
lets surgeons produce a watertight seal quickly, and it goes
without saying that this would go a long way in aiding the
recovery of a patient, never mind that one does not have
Wolverine’s healing factor. When inside the operating
cavity, the surgeon can squeeze the handle leavers in order
to release a couple of blunt needle guides, where said guides
are specially positioned in a perpendicular manner to the
5. 169
CHAPTER 12: Laparoscopic Port Closure Technique
port plane. With the activation button pressed, it will release
the needles from the guide, via the tissue and back to the
NeatClose cartridge. Once the system is pulled outside the
port, you can be sure that a safe and efficient airtight seal is
created, hence aiding the recovery of a patient for surgery
quickly. Now we are still waiting for a painless method
without the need for anesthesia.
Carter-Thomason CloseSure System—Port-site
Closure (Figs. 11A and B)
Closing any trocar site is a simple, fast and safe procedure
with the Carter-Thomason CloseSure System. The cone-
shaped Pilot®
Guide correctly angles the suture passer to
achieve full-thickness closure. It closes the port including
fascia and peritoneum (preventing Richter’s hernias)—
while maintaining pneumoperitoneum. The guide’s unique
design ensures precise placement of the suture passer for
consistent, reproducible results on any body type.
VersaOne™ Fascial Closure System (Figs. 12 and 13)
Port-site hernias are serious complications across
procedures and are a burden on patients, clinicians, and
health systems. Appropriate port-site closure is considered
to be one of the most critical factors for the prevention
of port-site herniation. The VersaOne™ Fascial Closure
System is a novel all-in-one device that serves as a trocar
and fascial closure device to deliver consistent port-site
closure and suture placement. The unique system
features a special cannula that allows for defect closure
without the need of additional devices.
As a result, the VersaOne™ Fascial Closure System:
■ Provides procedure efficiency
■ Eliminates the need to remove the trocar before closing
■ Makes reinsufflation unnecessary—pneumoperitoneum
can be maintained throughout the procedure
■ Enables tissue layers to remain aligned.
B
A
Figs. 11A and B: Carter-Thomason CloseSure System—port-site closure.
Fig. 12: VersaOne™ Fascial Closure System with its trocar. Fig. 13: VersaOne™ Fascial Closure System demonstrating
insertion of suture.
6. 170 SECTION 1: Essentials of Laparoscopy
Fig. 14: Remove the stylet from the cannula. Fig. 15: Pass a suture material through the cannula from the tip.
Fig. 16: Take suture out from the other end. Fig. 17: Tie the loop and hide the knot in the cannula.
There are a number of methods of post site closure
but there is no gold standard. Use of traditional suturing
techniques are difficult due to blind closure of the fascial
defect. Varying degrees of success are achieved by modified
hand suturing techniques. Finding the rectus sheath and
suturing through the layers of a thicker abdominal wall
through a relatively small hole is challenging particularly
in the obese. In such cases, we need special instrument for
efficientclosureoftheportsite.Veressneedleisaninstrument
that is commonly used for creating pneumoperitoneum but
it has been used to close the port site efficiently under vision.
VERESS NEEDLE TECHNIQUE OF
PORT CLOSURE
In 1983, Janos Veress of Hungary developed a specially
designed spring-loaded needle. Interestingly, Veress did not
promote the use of his needle for laparoscopy purposes. He
used Veress needle for the induction of pneumothorax. But
now Veress needle is the most important instrument today
to create pneumoperitoneum. Veress needle consists of an
outercannulawithabeveledneedlepointforcuttingthrough
tissues. Inside the cannula of Veress needle is an inner stylet,
stylet is loaded with a spring forward in response to the
sudden decrease in pressure encountered upon crossing the
abdominal wall and entering the peritoneal cavity.
TECHNIQUE OF PORT CLOSURE BY VERESS
NEEDLE (FIGS. 14 TO 25)
Occlude the port site with a finger so that the pneumo-
peritoneum is maintained and pass the Veress beside the
fingerthroughallthelayersexcepttheskinandsubcutaneous
tissue under vision. Maintenance of pneumoperitoneum is
important as it is very difficult to close the port if vision is
compromised.
Minimal access surgeries are the present and future of
surgical procedures and no surgery is complete without port
site closure. There are a lot of methods to close the port-site
but no gold standard. This procedure with the Veress needle
is safe, efficacious, and cost-effective.
One of the preventable complications is port-site
incisional hernia (PIH), which could develop at any port
site, most frequently at the midline, possibly because of
the absence of supporting muscle. The incidence of PIH
is variable from center to center, depending on several
factors including surgical technique and of course surgical
experience.
7. 171
CHAPTER 12: Laparoscopic Port Closure Technique
Fig. 18: Insert the suture material (that should close the port site) into
the cannula tip about 2 cm deep and bend it so that it stays in place.
Fig. 19: Now Veress needle is ready for port closure.
Fig. 20: Veress needle inserted with loop and tying
suture on one side.
Fig. 21: Retract the Veress and the suture is automatically
retained inside.
Fig. 22: Insert the Veress from the other side of the defect. Fig. 23: Entangle the suture in the loop of the Veress.
The trocar diameter, trocar design, pre-existing fascial
defects, tissue retrieval from the port site, and some
operation and patient-related factors, direction of the port
insertion, use of drain are the risk factors for development
of PIH. In obese and bariatric patients because of larger
preperitonealspaceandelevatedintra-abdominalpressure,
the risk of formation of trocar site hernia is greater. Size of
the port is another major risk factor and it is advisable to
close the hole >5 mm at the fascia level.
The meticulous closure of the laparoscopic ports is
important to prevent and reduce the chances of formation
of PIH. Port-site closure by Veress needle is an efficient
8. 172 SECTION 1: Essentials of Laparoscopy
Fig. 24: Tighten the loop and retract the Veress along with the suture
and tie the knot outside.
Fig. 25: Thus, the port site closed under vision and is safe procedure.
and safe technique done under vision and there is no need
to buy additional equipment to close the port site thus
cost effective.
The hernia may become evident at any time following
laparoscopic surgery and the patient may either have an
uncomplicated hernia, or may be afflicted with a variety of
complications such as evisceration of the bowel or omentum
and it may become a cause of significant morbidity.
Meticulous closure of the fascia, avoidance of unnecessary
wound extension, the use of nonabsorbable sutures when
faced with defects >2 cm in size, completely defining the
extent of any pre-existing hernia and repairing this at
the time of port-site closure, are recommended to minimize
the incidence of port-site hernia after laparoscopic surgery.
BIBLIOGRAPHY
1. Ahmad SA, Schuricht AL, Azurin DJ, Arroyo LR, Paskin DL,
Bar AH, et al. Complications of laparoscopic cholecystectomy:
the experience of a university-affiliated teaching hospital.
J Laparoendosc Adv Surg Tech A. 1997;7:29-35.
2. Al-Haijar N, Duca S, Molnar G, Vasilescu A, Nicolescu N.
Incidents and postoperative complications of laparoscopic
cholecystectomies for acute cholecystitis. Rom J Gastroenterol.
2002;11:115-9.
3. Azurin DJ, Go LS, Arroyo LR, Kirkland ML. Trocar site herniation
followinglaparoscopiccholecystectomyandthesignificanceofan
incidental preexisting umbilical hernia. Am Surg. 1995;61:718-20.
4. Baird DR, Wilson JP, Mason EM, Duncan TD, Evans JS, Luke JP,
et al. An early review of 800 laparoscopic cholecystectomies at
a university-affiliated community teaching hospital. Am Surg.
1992;58:206-10.
5. Bender E, Sell H. Small bowel obstruction after laparoscopic
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