LAPAROSCOPIC SURGERY AGUS SUPRIADI

INTRODUCTION SYNONYM KEY HOLE SURGERY BUTTON HOLE SURGERY MINIMALLY INVASIVE SURGERY MINIMAL ACES SURGERY

HISTORY 1983 : First laparoscopic appendicectomy by Kurt Semm , German gynecologist 1985 : First laparoscopic cholecystectomy by Erich Muhe, German surgeon 1987 : first laparoscopic repair of inguinal hernia by Ger 1991 : Ibrahim Ahmadsyah,first laparoscopic in Jakarta

FREQUENTLY DONE PROCEDURE ABDOMEN: Cholecystectomy incld Exploring CBD Appendicectomy Hernia Repair Adhesiolysis Diagnostic Bariatric/Sleeve Gastrectomy Colorectal tumour Fundoplication Achalasia

CHOLECYSTECTOMY Indications: Cholelithiasis Mucocele gallbladder Empyema gallbladder Thypoid carrier Porcelain gallbladder Acute cholecystitis

CHOLECYSTECTOMY Contraindications: Hemodynamic instability Uncorrected coagulopathy Generalized Peritonitis Severe cardiopulmonary disease Abdominal wall infection Multiple previous upper abdominal procedures Late pregnancy

CHOLECYSTECTOMY Advantage : Cosmetically better outcome Less tissue disection Less pain postoperatively Low intraoperative and postoperative complications Early return to work

APPENDICECTOMY Indications for laparoscopic : Female of reproductive age group Female of premenopausal group Suspected appendicitis High working class Previous lower abdominal surgery Obese patients Disease conditions like cirrhosis Immune compromised patients

APPENDICECTOMY Indications for Open Surgery Complicated appendicitis COPD or Cardiac disease Generalized peritonitis Stump appendicitis after previous incomplete appendicectomy

RISK FACTOR IN LAPAROSCOPIC APPENDICECTOMY Missed Diagnosis Bleeding Visceral Injury Wound Infection Incomplete Appendicectomy Leakage of Purulent Exudates Intra Abdominal Abscess Hernia

INGUINAL HERNIA REPAIR Indications : Bilateral Inguinal Hernias Recurrent Inguinal Hernias Contraindications : Non reducible,incarcerated inguinal hernia Prior laparoscopic hernioraphy Massive scrotal hernia Prior pelvic lymph node disection Prior groin irradiation

INGUINAL HERNIA REPAIR Advantages of laparoscopic repair: Tension free repair that reinforces myopectoneal orrifice Less tissue disection Less pain postoperatively Low intraoperatively and postoperatively complication Early return to work

Types of Laparoscopic Hernia Repair Simple closure of the internal rings Plug and patch repair Intraperitoneal onlay mesh repair Transabdominal pre peritoneal mesh repair (TAPP) Total Extra peritoneal repair (TEP)

COMPLICATIONS OF LAPAROSCOPIC HERNIA REPAIR Recurrence Neurovascular injury Urinary tract injury Iinjury to vas Testicular complications Problem due to mesh

LAPAROSCOPIC ADHESIOLYSIS Peritoneal adhesion is a common cause of bowel obstruction,pelvic and infertility Normal fibrinolytic activity prevents fibrinous attachments for 72 to 96 hours after surgery and mesothelial repair occurs within 5 days of trauma

The most important factors which suppress fibrinolytic activity and promote adhesion formation are : Port wound just above the target of dissection Tissue ischemia Drying of serosal surfaces Excessive suturing omental patches Traction of peritoneum Blood clots, stones or dead tissue retained inside

Prolonged operation Visceral injury Infection Delayed postoperative mobilization of patient Postoperative pain due to inadequate analgesia

DIAGNOSTIC LAPAROSCOPY 1.Non traumatic,Non gynecologycal,Acute Abdomen like : Appendicitis Diverticulitis Mesenteric Adenitis Intestinal Adhesion Omental Necrosis Intestinal Infarction Complicated Meckel’s diverticulum Torsion of intra abdominal testis

2.Gynecological Abdominal Emergencies like : Ovarian cyst PID Acute salpingitis Ectopic pregnancy Endometriosis Perforated uterus due to criminal abortion

CONTRAINDICATIONS Hemodynamic instability Mechanical or paralytic ileus Uncorrected coagulopathy Generalized peritonitis Severe cardiopulmonary disease Abdominal wall infection Multiple previous abdominal procedures

LAPAROSCOPIC FUNDOPLICATION Gastroesophageal reflux disease (GERD) is defined as the failure of the anti reflux barrier, allowing abnormal reflux of gastric content into the esophagus. Symptoms : Heartburn (retosternal burning ) 5-45% of adult in western countries Regurgitation

Pain Respiratory symptoms Diagnostic Test : Endoscopy Barium swallow Esophageal manometry pH monitoring

TREATMENT OF GERD Medical Therapy Esophagitis will heal approx 90% with intensive medical theraphy Symptoms recur more than 80% within one year of drug withdrawal Chronic condition , medical theraphy involving acid suppresion and pro motility agents may be required for the rest of patient’s life

2.Surgical Therapy Should be considered in individuals : Refractory to medical management Associated with hiatus hernia Intolerance to PPH or H2 receptors Not compliant to medical therapy Have complications of GERD , e.g Barrett’s esophagus,stricture, grade 3 or 4 esophagitis Atypical symptoms like : asthma,hoarseness,cough,chest pain and aspiration

METHODS OF FUNDOPLICATION The classical open methods The modern Laparoscopic techniques

Types of Laparoscopic Fundoplication Nissen Fundoplication Toupet Fundoplication Dor Fundoplication

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