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

2. PROLOGUE

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

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

5. 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 cm) as compared to larger incisions needed in traditional surgical procedures

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

7. 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

8. Other Endoscopic /Scopic surgery
Arthroscopy
Cranioscopy
Endoluminal

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

10. The light conductor invention
Phillip Bozzini ( )
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.

11. 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.

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

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

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

15. SPECTRUM
DIAGNOSTIC
THERAPEUTIC

16. 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

17. 1994 --- the introduction of robotics into the operating room.
GROWING SPECTRUM
TELEROBOTICS
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

18. 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]

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

20. 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

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

22. 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

23. 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

24. 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

25. THE ART AND THE CRAFT

26. THE EQUIPMENT
THE TECHNIQUE
THE TRAINING

27. THE EQUIPMENT

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

29. Trolley

30. 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.

31. 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

32. Telescopic rod lens system

33. 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

34. Video camera

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

37. 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).

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

39. Light source

40. Fiber optic cable

41. 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

43. Coagulation & cutting System
Diathermy monopolar / bipolar Harmonic

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

47. 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

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

49. Veress Needles

51. Trocars

53. Scissors

54. Dissectors

55. Graspers

56. Hook & spatula

57. Diathermy/harmonic dissector

58. Clip applicator

59. Staplers
Knotting devices
Suturing devices

60. Irrigation suction instruments

61. Irrigation suction instruments

62. Irrigation suction instruments

63. Retrieval instruments

64. Retrieval instruments

65. Retrieval instruments
Extractor

66. The technique
and the training

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

68. The learning curve
Step by step learning

69. SIMULATOR TRAINING-Endotrainers

70. SIMULATOR TRAINING-manikins

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

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

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

74. Module III. Conducting the procedures
Advanced Laparoscopic Procedures

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

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

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

78. Approach

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

80. Pneumoperitoneum

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

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

83. Mobilizing the Gall bladder

84. Aspiration

85. Dissecting in Callot’s triangle

86. Displaying the Cystic duct

87. Clipping the cystic duct

88. Cutting the cystic duct

89. Dealing with cystic artery

90. Dissecting out Gallbladder from liver bed

91. Preparing for Retrieval

92. Retrieval

93. Post-operative cholangiogram

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

95. 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

96. Thanks