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

2. 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.

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

4. 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

5. 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

9. 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

10. 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

11. 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.

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

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

14. Scissors HOOK SCISSORS, single action jaws
METZENBAUM SCISSORS, curved, length of blades 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.

15. 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.

16. 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 )

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

18. 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

19. PHYSIOLOGICAL CHANGES
co2
position
Physiological
changes
pneumoperitoneum

20. 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

21. 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

22. 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

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

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

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

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

27. 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

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

29. 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.

30. 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.

31. 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.

32. 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

33. Laparoscopic Surgery

34. Laparoscopic appendicectomy

35. 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