Introduction to Minimally Invasive Surgery (Laparoscopic Surgery) By: Abdul Aziz Alsaigh. FRCS, FACS Prof. of Laparoscopic Surgery

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

TYPES Intraperitoneal Extraperitoneal Abd wall retraction (gasless laproscopy) Hand assisted (Hassans tech.)

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

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

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

Trocar The trocar has a blade with a shaft and body. The body includes a pointed tip which makes the initial incision in the abdominal wall of the patient. (Trocar diameters range from 2mm-30 mm) Most common trocer is 5mm & 10mm

Optic Cables These cables are made up of a bundle of optical fibers glass thread swaged at both ends. The fiber size used is usually between 10 to 25 mm in diameter. They have a very high quality of optical transmission, but are fragile.

Dissecting & Grasping Forceps Atraumatic KELLY atraumatic Atraumatic, with hollow jaws MANGESHIKAR Grasping Forceps, serrated

Laparoscopic Hook It is used to separate adhesions, Used for diathermy purpose, To give traction to any organ.

Scissors HOOK SCISSORS, single action jaws METZENBAUM SCISSORS, curved, length of blades 12-17 mm, widely used as an instrument for mechanical dissection in laparoscopic surgery.    STRAIGHT SCISSOR can give controlled depth of cutting because it has only one moving jaw.

General instruments Reusable three-piece design Dispel are commonly used Available in 2 mm, 3 mm, 3.5mm, 5 mm and 10 mm sizes, with lengths of 20 cm, 30 cm, 36 cm and 43 cm. Choice of handle styles. Fully rotating 360° sheath. No hidden spaces that can trap operative blood and tissue debris.

Gases used to create pneumoperitoneum : Gas Insufflators Pneumoperitoneum is created upto 15mmHg which distends the abdominal cavity for proper visualization Gases used to create pneumoperitoneum : Air O2 CO2 : most common N2O : prefered for patients with cardiac disease He, Ne, Ar ( new )

Why CO2 is commonly used to create pneumoperitonium ? Readily available Cheaper Easily absorbed by tissues Quickly released via respiration

Technique Head end of the table is lowered to have easier insertion of needle scope Pressure bandages are applied to both legs to improve the venous return NG tube and foley’s catheter are essential before insertion of the trocars Pneumoperitoneum is created using veress needle through umbilical incision

PHYSIOLOGICAL CHANGES co2 position Physiological changes pneumoperitoneum

Physiologic changes due to pneumoperitoneum CO2 causes hypercarbia, acidosis and hypoxia Pneumoperitoneum exerts pressure on the IVC, decreases the venous return and so the cardiac output Increase the arterial pressure Compromises the respiratory function by compressing over the diaphragm imparing the pulmonary compliance

Laparoscopic Port Positions PRIMARY PORT POSITION SECONDARY PORT POSITION Attractive primary port is the umbilicus because of 1. central location and 2.the ability of the umbilicus to hide scars Umbilicus is a naturally weak area due to absence of all the layers Its location is at the midpoint of the abdomen’s greatest diameter. Varying of operation According to the surgeon preference

Basic Diamond Concept of Port Position Mainly two port 5mm and 10mm port Laparoscope is inserted through the umbilical port (10mm port) Clip applicator 10mm port is essential Additional ports ( 3-4) through trocars are placed depending on the procedures may be 5mm or 10mm port

Basic Diamond Concept of Port Position (5mm) Port position for cholecystectomy (10mm) (5mm) Port position for appendectomy

What operations can we do Laparoscopically Cholecystectomy Appendicectomy Hernia repair Division of adhesions Closure of perforation Hiatus hernia repair.

What operations can we do laparoscopically? Bowel resection Repair of Prolapse Nephrectomy Bypass Spleenectomy

What operations can we do Laparoscopically Anterior resection/ APR Right Hemicolectomy Left/Sigmoid Colectomy Gastrectomy Oesophagogastrectomy

Diagnostic laparoscopy Needle laparoscopy of 2mm sized becoming popular Indication Acute pelvic conditions Tubal pregnancy Ovarian diseases Infertility Staging of the malignancy Biopsy from the tumors In chronic pain abdomen where ultrasound, endoscopies, barium studies are negative

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

Principle Differences between Laparoscopic and Open Surgery FOR THE PATIENT Post operative pain related to size of incision- smaller incisions =less pain. Less Handling of intestines results in little or no disturbance of normal function. Avoidance of the trauma of abdominal wall injury by the incision allows rapid return to normal activity No incision allows early return to more strenuous activities: driving, lifting, sport etc.

Principle Differences between laparoscopic and open surgery FOR THE HOSPITAL Initial capital costs to establish laparoscopic surgery in the order of £30,000 - £40,000 Reduced overall costs by shortening of hospital stay e.g. cholecystectomy reduced from 5 to 1 day, hiatus hernia repair reduced from 7 to 3 days.

Principle Differences between laparoscopic and open surgery For the Surgeon Magnified view often better than obtained via an incision allows precise dissection. Altered (but not absent) tactile response Two dimensional (flat screen) view. Usually (but not always) longer operating time Need to develop entirely different operating technique Adaptation of principles of open surgery to laparoscopic surgery.

Advantages of laparoscopic surgery 1. Less post operative pain 2 Advantages of laparoscopic surgery 1. Less post operative pain 2. Faster recovery time 3. Shorter hospital stay 4. Smaller scars 5. Less internal scarring 6. Less risk of wound infection and incisional hernia 7. Better visualization of anatomy

Laparoscopic Surgery

Laparoscopic appendicectomy

Complications Insertion Related : Post Insertional : Major vascular injury GI Injury Bladder injury CO2 embolism Abdominal wall haemorrhage Post Insertional : GI perforations Laceration & bleeding from solid organs Abdominal wall hernia Pneumoperitoneal Related: Hypercarbia Respiratory acidosis Subcutaneous emphysema Renal failure Venous thrombosis Pneumothorax