AN INTRODUCTION TO LAPAROSCOPIC SURGERY By; Col.Abrar Hussain Zaidi

PROLOGUE

THE ORIGIN Innate Human Desire – to Be Minimally Harmed / Surgically

This thought makes the foundation of what is now referred to as minimally invasive surgery.

Nomenclature Minimally invasive surgery (MIS), bandaid surgery, keyhole surgery, or pinhole surgery is a modern surgical technique in which: operations are performed through small incisions (usually 0.5-1.5cm) as compared to larger incisions needed in traditional surgical procedures

Nomenclature Scopic surgery Endoscopic surgery. broader term For the use of an endoscope Laparoscopic /Thoracoscopic/others

Nomenclature Laparoscopic surgery Laparoscopic surgery includes operations within the abdominal or pelvic cavities Thoracoscopic surgery.[VATS] MIS surgery performed on the thoracic or chest cavity

Other Endoscopic /Scopic surgery Arthroscopy Cranioscopy Endoluminal

HISTORY A physician’s desire to evaluate the inside of a patient's body with limited injury existed as far back as Hippocrates (460-375 B.C.). He made reference to examination of the rectum with a speculum.

The light conductor invention Phillip Bozzini (1773-1809) The light conductor invention In 1901 George Kelling examine the abdominal cavity of dogs Jacobeus [1901--?] a surgeon from Stockholm, coined the phrases "laparoscopie" and "thoracoscopie". first to publish a series of abdominal and thoracic examination in humans using minimally invasive techniques.

Bertram Berheim from Johns Hopkins in 1911 to perform the first laparoscopy in the United States. The advent of the insufflator (Kurt Semm), fiberoptics and the rod-lens system (Harold Hopkins)-1958.

First solid state camera in 1982 1987 - Phillipe Mouret performed the first laparoscopic cholecystectomy. An ignition for the laparoscopic surgery.

During the past <two decades, a dynamic evolution in Minimally Invasive Surgery has occurred that has no equal in the history of surgery

SPECTRUM The world of MIS has expanded during the last decade to include most surgical fields; Abdomen and thorax Brain and heart, Gynaecology Orthopaedics

SPECTRUM DIAGNOSTIC THERAPEUTIC

SPECTRUM Diagnostic TB/Crohn’s Diverticulitis Lymphadenopathy Benign renal disease Gastric Obstruction Some Splenic disorders Operative Cholecystectomy Appendicectomy Bowel resection Repair of Prolapse Nephrectomy Bypass Spleenectomy Gynaecological

1994 --- the introduction of robotics into the operating room. GROWING SPECTRUM TELEROBOTICS 1994 --- the introduction of robotics into the operating room. A robotic arm was used to hold the camera replacing the camera operator. 1996- a surgery was performed with the patient and surgeon in different locations using the Internet - Telesurgery

The operating room of tomorrow Future Technologies yet to be introduced - seem boundless. The operating room of tomorrow may not be the same as it is today. Your presence right there may not be necessary [ thanks to telerobotics]

Conceptual debates - ISSUES Post-operative pain Recovery / Hospital stay Visual field for surgeons Operation time Cost Cosmetic outcome Patient acceptance The complications

Advantages/ benefits Reduced post operative pain and analgesic requirement Reduced operative trauma Reduced bleeding Faster recovery, discharge and return to work Reduced wound infection, seroma and haematoma Reduced chronic wound pain Less cardiorespiratory complications

Advantages/ benefits Less ileus from reduced handling Improved cosmesis Reduced contamination of theatre staff (Hepatitis and HIV) Interesting for surgeons Reduced outpatient/social costs

Advantages/ benefits Reduced risk of DVT/PE Reduced incisional hernia rate Fewer adhesions and less likely to develop obstruction Immunological benefits Better visualisation for the surgeon

Disadvantages/ Risks High risk of co-lateral injury eg Common bile duct in lap cholecystectomy Bowel/bladder/vascular injury in hernia surgery Verres needle injury Diathermy may lead to organ damage eg late cbd stricture Increased operating time

Disadvantages/ Risks Increased costs due to theatre time and equipment Tumour seeding Poor quality surgery eg cancer resection Loss of tactile sensation Long learning curve Loss of training opportunity eg appendicitis and inguinal hernia Some surgeons not able to develop skills

THE ART AND THE CRAFT

THE EQUIPMENT THE TECHNIQUE THE TRAINING

THE EQUIPMENT

The Equipment Laparoscope/video system Light source Insufflator Diathermy /coagulation:cutting system [+Harmonic ace] Suction irrigation system Specialized hand instruments

Trolley

The Equipment Laparoscope/video system There are two types: Telescopic rod lens system, that is connected to a video camera (single chip or three chip) or A digital laparoscope where the charge-coupled device[CCD] is placed at the end of the laparoscope, eliminateing the rod lens system.

Telescopic rod lens system There are three important structural differences in telescope available in the market. 6 to18 rod lens system telescopes 0 to 120 degree telescopes 1.5 mm to 15 mm of telescopes

Telescopic rod lens system

Video camera Single chip VS three chip Three primary colours (Red,Blue, Green). In single chip camera all these 3 primary colours are sensed by single chip. In three chip camera there are 3 CCD- Chips for separate capture and processing of 3 primary colours—High resolution

Video camera

Monitor No different from the T.V. Basic principle of image reproduction is horizontal beam scanning on the face of the picture tube.

The existing television systems in use differ according to the country. The U.S.A uses the NTSC (National Television System Committee) system. In European countries the PAL (Phase Alternation by Line) system is in use. French system called SECAM (Sequential color and memory).

Light source A fiber optic cable system connected to a 'cold' light source (halogen or xenon), to illuminate the operative field,

Light source

Fiber optic cable

Insufflator The abdomen is insufflated with carbon dioxide gas [pneumoperitomeum] to create a working and viewing space. Elevates the abdominal wall above the internal organs like a dome. Gasless surgery –with mechanical wall elevators

Coagulation & cutting System Diathermy monopolar / bipolar Harmonic

Specialized hand instruments A-ACCESS INSTRUMENTS B-DISSECTING/OPERATING INSTRUMENTS C-RETRIEVAL INSTRUMENTS

Specialized hand instruments 5-10mm diameter instruments Trocars & Ports---access devices Graspers Scissors Dissectors Clip applier,Knotting devices,Staplers Cutting /coagulation – hooks,spatulas,balls,forceps Irrigation suction tubes Retrieval instruments

Disposable vs Reusable instruments Conventional vs. Needle scopic /miniaturized instruments—2mm size

Veress Needles

Trocars

Scissors

Dissectors

Graspers

Hook & spatula

Diathermy/harmonic dissector

Clip applicator

Staplers Knotting devices Suturing devices

Irrigation suction instruments

Irrigation suction instruments

Irrigation suction instruments

Retrieval instruments

Retrieval instruments

Retrieval instruments Extractor

The technique and the training

Learning the art parallels the steps followed in actual performance of a Laparoscopic procedure

The learning curve Step by step learning

SIMULATOR TRAINING-Endotrainers

SIMULATOR TRAINING-manikins

Module I. Preoperative Considerations Patient Selection /surgical indications Preoperative Assessment Preparation Laparoscopic Equipment Energy Sources OR Set Up

Module II. Intraoperative Considerations Anesthesia Patient Positioning Pneumoperitoneum Establishment /Physiology of Pneumoperitoneum Trocar Placement Exiting the Abdomen

Module III. Conducting the procedures Basic Laparoscopic Procedures Diagnostic Laparoscopy Biopsy Laparoscopic Suturing Hemorrhage & Hemostasis

Module III. Conducting the procedures Advanced Laparoscopic Procedures

Module IV. Postoperative Care Surgical Injuries Pneumoperitoneum Complications and Dealing with.

Module V. Manual Skills Instruction and Practice Training Exercises Record and audit/Data Analysis Research

LAPAROSCOPIC CHOLECYSTECTOMY Indications patient selection Consent/special features Preparation Procedure Post-operative care Record and audit

Approach

Positioning and setting the instruments Check the diathermy Focusing & White balancing of camera Pressures

Pneumoperitoneum

Insertion of access ports Camera Grasping and holding instruments Dissecting instruments Additional

Inspection -diagnostic laparoscopy Primary area of concern Rest of the cavity Resectability Adhesions

Mobilizing the Gall bladder

Aspiration

Dissecting in Callot’s triangle

Displaying the Cystic duct

Clipping the cystic duct

Cutting the cystic duct

Dealing with cystic artery

Dissecting out Gallbladder from liver bed

Preparing for Retrieval

Retrieval

Post-operative cholangiogram

Re-inspection Irrigation suction Drain Deflation Check the ports Close the incisions Carefully collect the instruments/equipment

CONCLUSION LEARNING THE CRAFT OF MIS WILL BE UNAVOIDABLE IN NEAR FUTURE IN EVERY SURGICAL SPECIALITY MOLD YOUR MINDS AND INCLINE TOWARD LEARNING THE BASICS OF SCOPIC SURGERY

Thanks