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Laparoscopy
- 1. MINIMAL INVASIVE SURGERY LAPAROSCOPY& HYSTEROSCOPY Dr Aisha Nazeer Assistant Professor Deptt of OB-GYN Civil Hospital,Bahawalpur
- 2. BASICS OF LAPAROSCOPY Laparoscopyliterally means, "to look inside the abdomen".
- 3. Laparoscopy A surgical procedurein which a fibre-optic instrument is inserted through the abdominal wall to view the organs in the abdomen or permit small-scale surgery with help of pneumoperitoneum
- 4. Laparoscopic surgery Laparoscopic surgery,also called minimally invasive surgery (MIS), bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations are performed far from their location through small incisions (usually 0.5–1.5 cm)
- 5. History 1805, Bozzini, anobstetrician, using candlelight through a tube attempted to examine urethra and vagina 1910, Jacobaeus, performed laparoscopy using a cystoscope 1920s & 1930s, Kalk, a gastroenterologist, popularised diagnostic laparoscopy Origin of modern laparoscopic surgery- Kiel School in Germany, headed by Semm, a gynaecologist. Dr. Camran Nezhat - “FATHER OF MODERN LAPROSCOPIC SURGERY” introduce video laparoscopy 1901: George Kelling, Dresden, Saxony (Germany) performed 1st experimental laparoscopy on dog, calling it ‘Celioscopy’
- 6. ADVANTAGES Reduced postoperative morbidity- pain, chest & wound complication Accelerated recovery Lesser adhesion formation Better cosmesis Reduced contact with body fluids & disease transmission Reduced incidence of ventral hernia- 11% in midline vs 4.7% in transverse scar vs 0.7% after laparoscopy. MAGNIFICATION PRECISION DOCUMENT- ATION
- 7. DISADVANTAGES Expensive equipment Learning curve Limitationof intact organ retrieval(tumours) Trocar related injuries to vessels and viscera Counter-intuitive motion Diathermy burns Hemostasis more difficult Williams Gynecology 2nd Edition A guide to laparoscopicInsufflation related postoperative pain surgery
- 8. INDICATIONS CONTRAINDICATIONS Diagnostic- Infertility Acute and chronic pelvic pain Therapeutic- Ectopic pregnancy Endometriosis & infertility Ovarian cyst, adnexal torsion Hysterectomy Myomectomy Prolapse repair Mullerian anomalies Oncosurgery Contraindications to GA/ pneumoperitoneum- Cardio-respiratory Uncorrected coagulopathy Major haemorrhage requiring rapid control Intestinal obstruction(severe distension) Acute glaucoma Increased intracranial pressure, peritoneal shunts
- 9. Basics of laparoscopy- Instruments Verres needle Used to inflate air/CO2 to the peritoneal cavity (pneumoperitoneum) through the umbilicus where there is the thinnest abdominal wall.
- 10. Basics of laparoscopy- Instruments Electronic laparoflator: Insufflator Used to insufflate through the verres needle. Maintains constant intra-abdominal pressure without exceeding the safety limit.
- 11. Basics of laparoscopy- Instruments Trocars Permit access to the intra-peritoneal cavity in which other instruments can pass. The trocar used should be adapted to the diameter of the telescope selected
- 12. Basics of laparoscopy- Instruments Telescope There are different sizes and angles, each with a different use. They are used to visualize the peritoneal cavity.
- 13. Basics of laparoscopy- Instruments Camera equipment & Light source
- 14. Basics of laparoscopy- Instruments Forceps and scissors There are two types: ◉ Disposable ◉ Reusable They can be either atraumatic or grasping foreceps.
- 15. ANESTHESIA POSITIONING Steep, head-down (15-20°) (Trendelenburgposition) Low lithotomy position of legs Adequate padding (avoid common peroneal nerve Knees in slight flexion(<90°) (avoid sciatic nerve stretching) Hips in slight abduction(<45°)(avoid femoral nerve Left arm by side of patient(avoid brachial nerve inj bowel displaced injury) GA preffered with endo tracheal tubing KK Roy et al., Arch Gynecol Obstet (2014) 289:337–340
- 16. Basics of laparoscopy- Procedure Preparation of the patient: ◉ Inform the patient about the therapeutic benefits and potential risks (informed consent). ◉ Intestinal preparation: Simple intestinal emptying, for better viewing and preventing injuries.
- 17. Basics of laparoscopy- Procedure Creating a pneumoperitoneum: • The abdominal wall is lifted by hand or by grasping forceps ◉ Pnemoperitoneum is created by verres needle introduced to the umbilical area ◉ The needle is inserted in an oblique angle toward the uterine fundus ◉ The negative pressure will allow the underlying structures to fall away. ◉ After making sure that the needle is in correct position, air flow can be increased to 2.5 L/min till a pressure of 15mmHg
- 18. Basics of laparoscopy- Procedure Trocar introduction Once the intra-abdominal pressure reaches 15 mmHg the main trocar is introduced after removal of veress needle. The position of the trocar must be verified by inserting the laparoscope and viewing the pelvic cavity.
- 19. Basics of laparoscopy- Procedure Viewing the peritoneal cavity The omentum, bowel and bifurcation of pelvic vessels should be evaluated to avoid injuries caused during the introduction of Verres needle or trocar. The site of introduction of other trocars should be verified by finger palpation and transillumination of abdominal wall to avoid injury to epigastric vessels.
- 20. Basics of laparoscopy- Procedure During the operative procedure • 1 or 2 bottles of Ringer’s lactate are used to wash the peritoneal cavity after laparoscopy. • Leave 500/1000 ml of ringer’s lactate to reduce the incidence of post operative pain. After the procedure • CO2 gas must be evacuated completely to reducepost-operative pain
- 21. Laparoscopy – inEctopic pregnancy
- 22. Laparoscopy – inPelvic Inflammatory Disease (PID)
- 23.
- 24. Laparoscopy – inEndometriosis
- 25. Laparoscopy – inOvarian Cysts Most ovarian cysts are haemorrhagic corpora lutea or follicle cysts. They are usually asymptomatic and when they cause pain it is almost always acute. Laparoscopic evaluations of patients with CPP reveal ovarian cysts on average in only 3% of all cases.
- 26. Laparoscopy – inOvarian Cysts Even when the surgeon is ‘certain’ that the ovary is benign, it is essential that tissue be sent for histological evaluation. Open the cyst and inspect the lining for papillary structures or excrescences. If these are noted, then a laparotomy should be done
- 27. Laparoscopy – inAdnexal Torsion A rare gynecologic emergency that nearly always occurs unilaterally. Relapse or bilateral adnexal torsion can cause sterility interfering with fertility. In 30% of the patients, there is torsion of a normal adnexa, while the majority of the cases are associated with ovarian pathology.
- 28. Laparoscopy – inAdnexal Torsion Conservative management by laparoscopy is the best approach when tissues are viable and should be carried out promptly to preserve the adnexa (basic principles of conservative management are to untwist the structure and treat the underlying cause ‘ie - ovarian cyst’). Once untwisted, the organ must be observed to ensure color change to normal, confirming viability and blood supply.
- 29. Laparoscopy – inLeiomyomata (fibroids)
- 30. Laparoscopy – inOncologic procedures For second-look procedures following surgical and chemo treatment of malignancy. Laparoscopy has also been used for staging, including peritoneal washes with biopsy, partial omentectomy, and pelvic and periaortic lymphadenectomy Laparoscopically assisted radical vaginal hysterectomy have also been used by some gynecologic oncologists.
- 31. Laparoscopy – Tubalsterilization Tubal sterilization can be done using: ◉ Bipolar coagulation ◉ Clips (filshie clips) and rings Before the procedure, inform patient about: • Chance of irreversibility • Failure rate 1/200 • Bleeding may occur and we may shift to laparatomy.
- 32. Laparoscopy – riskfactors Patient related risk factors ◉ Obesity ◉ Age ◉ Previous abdominal surgery Anesthetic risk factors ◉ Time since last oral intake ◉ Heart disease ◉ Pulmonary disease
- 33. LPatient related riskfactors Obesity ◉ Laparoscopy becomes more difficult and potentially more risky. ◉ Placement of laparoscopic instruments becomes much more difficult ◉ Bleeding from abdominal wall vessels may be more common because these vessels become difficult to locate. ◉ Restricted operative field secondary to retroperitoneal fat deposits in the pelvic sidewalls and increased bowel excursion into the operative field
- 34. Laparoscopy – Patientrelated risk factors Age ◉ Older patients are at increased risk of having concomitant disease processes that affect their perioperative morbidity and mortality
- 35. Patient related riskfactors Previous abdominal surgery ◉ Risk of adhesions of omentum and/or bowel to the anterior abdominal wall after previous abdominal surgery is greater than 20%. ◉ As laparoscopy requires the insertion of sharp instruments into the abdominal cavity, a reasonable assumption is that previous surgery would increase the risk of bowel injury
- 36. pre-op work-up 1. Completeblood cell count 2. Pregnancy test 3. Urinalysis 4. ECG 5. Other: • In patients with known health problems, other laboratory tests, such as liver function tests or electrolyte evaluations, may be indicated. • A thorough preoperative medical evaluation, including appropriate laboratory studies 6. Imaging studies: • Chest radiography • Intravenous pyelograph or kidney ultrasoundarium enema
- 37. Laparoscopy possible complications Laparoscopic procedureshave unique risks, related to: • methods used for the placement of abdominal wall ports • pneumoperitoneum required for laparoscopy 1. Pneumoperitoneum related complications 2. Injury to abdominal organs 3. Blood vessel injury
- 38. Laparoscopy complication:Pneumoperitoneum Pneumoperitoneum relatedcomplications • Extra-peritoneal emphysema due to failure of introducing verres needle correctly into the peritoneal cavity and not checking the negative pressure on the machine. • Gas may extend to the mediastinum and compromise cardiac function • Pneumo-omentum • Increased intra-abdominal pressures may increase anesthesia- related risks such as aspiration and increased difficulty ventilating the patient
- 39. Laparoscopy complications –abdominal organs Injury to abdominal organs • GI: if the intestine is distended or adherent to the abdominal wall (prevented by good intestinal preparation) and putting the patient on the telendelenburg position. • Bladder injury: prevented by emptying the bladder.
- 40. Laparoscopy complications –blood vessel injury Blood vessel injury: ◉ Pelvic, omental and mesentric blood vessel injury ◉ Prevented by introducing the verres needle in an angle. ◉ Although the risk of blood loss is relatively low, potentially massive blood loss may occur and is complicated as control may be delayed because of the time taken to perform an emergency laparotomy.
- 41. recent advances 3 innovationsthat have been introduced in the field of laparoscopy: ◉ Robotic surgery ◉ Natural orifice transluminal surgery (NOTES) ◉ Single incision laparoscopic surgery (SILS). Of these 3 developing technologies, robotic surgery is having the largest impact on clinical care.
- 42. Laparoscopy – roboticsurgery Robotic system advantages: • 3-dimensional, high-definition imaging and magnification. • Fully articulated instruments emulate the full range of motion of a surgeon’s wrists and hands. • Enhances the surgeon’s ability to remotely perform fine motor skills such as intricate dissections and intracorporeal suturing that remain difficult during traditional laparoscopy.
- 43. Laparoscopy – roboticsurgery Robotic system advantages: • Robotic tools attach to traditional laparoscopic ports and the robotic system is placed between the patient’s legs for hysterectomy. The surgeon controls the instruments from a console located in the same room. • Direct correlation between hand movements and instrument movements.
- 44. Natural orifice transluminalsurgery Using an endoscope to access the abdominal cavity through existing body openings (Ex: mouth, rectum, and vagina) Modern NOTES uses a flexible endoscope to access the peritoneal cavity by creating an incision in the stomach or colon.
- 45. Single incision laparoscopicsurgery Single incision laparoscopic surgery (SILS) refers to performing laparoscopy through a single incision.
- 46. Advantages vs disadvantages ◉Minimizes the number of incisions ◉ In turn results in decreased pain, improved cosmetics ◉ Reduces the risks associated with a secondary port placement. Advantages Disadvantages visibility, depth perception, maneuverability, reach, and the ability to create counter-traction are all limited.
- 47. Laparoscopy – riskvs benefit Laparoscopy is a hybrid surgical approach that shares characteristics of both minor and major surgery. To patients, laparoscopic procedures often seem to be minor surgery because of the small incisions, relatively small amount of postoperative pain, and short convalescent period. Its an intra-abdominal procedure - therefore, it shares all intraoperative and postoperative risks of laparotomy, including infection and injury to adjacent intra-abdominal structures
- 48.
- 49. HISTORY First attemt forvisualisation of abdominal organ- Bozzini 1806 – illumination of urethra by candle Pantaleoni 1869 introduced hysteroscopy for diagnosis of intrauterine ds. Rubin 1925 : used cystourethroscope to look into uterus. Used water to distend Uterus and to wash lense, used carbondioxide 1990s : Hysteroscopic surgical procedures became popular , demonstrated equivalent or better results than traditional laparoscopic surgery of uterus
- 50. Hysteroscopy involves passinga small diameter telescope either flexible or rigid through the cervix to directly inspect the uterine cavity. Excellent images can be obtained. Flexible hysteroscope: may be used in outpatient settings Rigid instrument: employ circulating fluids therefore can be used to visualize uterine cavity even if the women is bleeding.
- 51. Flexible Endoscopes Rigid High cost Fragility problem insterilization Oº , 12º, 30º.. Diagnostic Operative Resectoscope HYSTEROSCOPE
- 52. TYPES Rigid hysteroscope 4-mm scopeoffers the sharpest and clearest view Narrow, 3.5 mm - minimal dilation of the cervix. Ideal for office hysteroscopy Flexible hysteroscope • Can deflect over a range of 120-160° • New equipment replaces image fiber bundle with a video chip, eliminating unwanted ground glass artifact (Moire effect) • Directed biopsies,transcervical tubocornual recanalization, chorionic villus sampling, IUD retrieval
- 53. LiquidGas CO2 LMW Electrolyte - Normal Saline Nonelectrolyte 1.5% Glycine Sorbitol/Mannitol 5%dextrose , - Ringer lactate 32% dextran Nontoxic Transmits light Good view Does not mix with blood Not used Commonly DISTENSION MEDIA HMW
- 54. Best time- 1sthalf of menstrual cycle Isthmus hypotonic Endometrium proliferative Less cervical mucus Less risk of unexpected pregnancy Positioning : low dorsolithotomy Preparation of cervix : for cervical stenosis Misoprostol 200-400mcg sl/pv 30min - 6 hrs before procedure Inj. Vasopressin Intracervical 0.05 U/mL, 4 cc at 4 and 8 o'clock
- 55. HYSTEROSCOPY INDICATIONS : Abnormaluterine bleeding Post Menopausal bleeding Abnormal HSG/USG Uterine abnormalities (septae) Suspected intra- uterine pathology (polyps, myomas,adhesions,foreignnbodies) Recurrent Pregnancy loss Before IVF Unexplained infertility o Hysteroscopy is considered the gold standard for diagnosis of intrauterine lesions o Transvaginal sonography / HSG and are most commonly used for UTERINE CAVITY ABNORMALITY CONTRAINDICATIONS • Acute PID • Active herpes infection • Pregnency • Medically Unstable patient Endometrial polyp Cystic endometrial changes
- 56. OFFICE HYSTEROSCOPY Hysteroscopy doneat outpatient basis without anaesthesia/ analgesia & cervical dilatation Vaginoscopical approach (no-touch) : Most popular approach: first Routine prophylactic antibiotic not recommended Vaginoscopic approach, preserves integrity of hymen proposed by BETTOCCHI AND SELVEGGI in 1996 No need for use of speculum and tenaculum Vaginal cavity distended using distension media Decreased patient discomfort (99.1%) No assistants required <3.5mm rigid hysteroscope / flexible hysteroscope Patient can herself observe normal and abnormal findings ACOG 2011 ; Kerkvoorde et al 2
- 57. OUTPATIENT HYSTEROSCOPY NSAIDs 1hour before hysteroscopy: reduce pain in immediate postoperative period Routine cervical preparation before outpatient hysteroscopy: not be used Miniature hysteroscopes (2.7mm with 3–3.5mm sheath) should be used for diagnostic outpatient hysteroscopy, significantly reduce discomfort experienced Flexible hysteroscopes : less pain during outpatient hysteroscopy Rigid hysteroscopes may provide better images, fewer failed procedures, quicker examination time and reduced cost Uterine distension with normal saline RCOG Green-top Guideline No. 59 (2011 LOR B A A B A of efficacy en
- 58. Topical application oflocal anaesthetic to ectocervix where application of a cervical tenaculum is necessary OUTPATIENT HYSTEROSCOPY LOR A A A A C Local anaesthetic into or around cervix reduces pain during hysteroscopy. Routine administration of intracervical or paracervical LA recommended in postmenopausalwomen Conscious sedation should not be routinely used in outpatient hysteroscopic procedures, it confers no advantage in terms of pain control and satisfaction over LA. Vaginoscopy reduces pain during diagnostic rigid outpatient hysteroscopy Routine cervical dilatation is associated with pain, vasovagal reactions and uterine trauma and should be avoided RCOG Green-top Guideline No. 59 (2011
- 59. OPERATIVE HYSTEROSCOPY INDICACTIONS POLYP SUBMUCOUS LEIOMYOMA UTERINE SEPTA INTRAUTERINEADHESIONS MISPLASED / IMBEDED IUD TUBAL CANNULATION & FALLOPOSCOPY TUBAL STERILIZATION
- 60. OPERATIVE HYSTEROSCOPE Used forminor surgery (Small endometrial polyp or pedunculated fibroid) Telescope passes through external sheath Diameter of extension sheath ranges between 3.5 and 7mm Extension sheath allows passage of both operative instrument and liquid distension media
- 61. Perforation Bleeding Fluid overload Infection Hematometra Hysteroscopic Complications Intraoperative •Pain • Air embolism • Fluid overload • Hemorrhage • Perforation • Thermal injuries Postoperative • Hemorrhage ,infection, hematometra ,adhesion Others • Non-resolution of symptoms • Spread of malignancy • Complications of pregnancy Viscous: Hypotonic: Pul. oedema, anaphylaxis Coagulopathy, renal failure Electrolyte imbalance, encephalopathy & consequences, Transient blindness
- 62. PERFORATION or Midline uterine -no significant morbidity Lateral uterine - retroperitoneal hematoma Cervical perforations - significant immediate delayed bleeding Recognition of perforation Loss of uterine distension Rapid increasing in fluid deficit Sudden uterine bleeding MANAGMENT With small dilator little risk to surrounding organ or major bleeding – conservative management With large dilator or electrical energy - laparoscopy needed Perforation has occurred , abandoned procedure and repeat hysteroscopy after 4- 6 weeks Prevention: • pelvic examination to determine uterine position • Pink myometrium becomes visible • Resection to be done till both ostia seen simultaneously • Laparoscopic guidance or USG guidance
- 63. COMPLICATIONS(cont.) Vasovagal attack Proper evaluationparticularly to rule out preexisting heart disease Instillation of LA in cervical canal may reduce incidence Routine administration of intracervical or paracervical LA is not indicated to reduce incidence Air Embolism OT assistant must keep a watch on Fluid bottle and inform surgeon before changing it to prevent entry of air bubble into uterus Mx - Left lateral decubitus position withthe head tilted downward 5 degrees f/b IJV catheter False passage Vaginal misoprostol 400ug 2-3 hrs before procedure
- 64. FLUID OVERLOAD Incidence 0.38%-3.3% Hypoosmolarityand hyponatremia--- cerebral edema and death Pulmonary edema & Coagulopathy Appropriate delivery system - Hysteromet infusion pressure < mean arterial pressure Absorption pressure ratio (APR) < 1. Avoid entering into vascular channels ACOG 2011, AAGL200
- 65. TAKE HOME MESSAGE Laparoscopyhas grown rapidly & become technique ofchoice Basic knowledge of instruments & energy sources is necessary beforeany surgery Primary incision for laparoscopy should be vertical from base of umbilicus Manometer test : most reliable test for veressentry Direct trocar entry : less minor complication & failedentry For failed entry/ scarred abdomen – open technique / palmer pointentry Non-midline incision ≥ 7mm & midline ≥10 mm requires deep sheathclosure Harmonic : poor maintenance of residual tip temperature & minimal thermalspread Ligasure : adequate maintenance of residual tip temperature but more lateral thermalspread Whenever possible use bipolar energy sources over mono-polar in lowest possiblevoltage
- 66. TAKE HOME MESSAGE Hysteroscopydone in 1st half of menstrualcycle For outpatient hysteroscopy vaginoscopic approach is preferred Miniature hysteroscopes (2.7mm with 3–3.5mm sheath) - significantly reduce patientdiscomfort Local Anaesthesia Intra cervical - reduces vasovagal symptoms, decreases thepain Para cervical - significantly decreases the pain, not reduces vasovagalsymptoms Distension media Normal saline 0.9% – diagnostic, operative hysteroscopy with instrument / with bipolar Glycine 1.5% - monopolar energy
- 67.