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Principles of Laparoscopic Surgery SAWA

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									PRINCIPLES OF
LAPAROSCOPIC
SURGERY
Done By :
Moath Al-Ahmad
Mohammad Abu Saud
Objectives
• Principles and the extent of laparoscopic surgery
• The Advantages and disadvantages of laparoscopic
  surgery
• The pre-operative , intraoperative and postoperative care
SHORT HISTORY
• 1981     Semm performed first Laparoscopic
           Appendectomy.
• 1987     Mouret performed first
            Laparoscopic Cholecystectomy.
Prior to 1990, the only specialty performing laparoscopy on
  a widespread basis was gynecology, mostly for relatively
  short, simple procedures such as a diagnostic
  laparoscopy or tubal ligation.
LAPAROSCOPIC SURGERY

         “KEYHOLE SURGERY”

     MINIMALLY INVASIVE SURGERY

      MINIMAL ACCESS SURGERY
DEFINITION
• Minimal Access surgery :a marriage of modern technology
 and surgical innovation that aims to accomplish surgical
 therapeutic goals with minimal somatic and psychological
 trauma.
• This type of surgery offers a cost-effectiveness both to
 health services and to employers by shortening the
 operation time , shortening hospital stays and shorter
 recovery time
 Broadly speaking, minimal access techniques can
be categorized as follows:
1. Laparoscopy
2. Thoracoscopy
3. Endoluminal endoscopy
4. Periviseral endoscopy
5. Arthroscopy and intra-articular joint surgery
6. Combined approach
Laparoscopy

• It is a rigid endoscope that is introduced through a sleeve into
  the peritoneal cavity.
• The abdomen inflated with carbon dioxide to produce a
  pneumoperitoneum. Further sleeves or ports are inserted to
   enable instrument access and their use for dissection.
• There is little doubt that laparoscopic cholecystectomy has
  revolutionized the surgical management of cholelithiasis and
  has become the mainstay of management of uncomplicated
  gallstone disease.
• With improved instruments and more experience it is
likely that other advanced procedures, such as laparoscopic
colectomies for malignancy, previously regarded as controversial
will also become fully accepted.
Thoracoscopy
• A rigid endoscope is introduced through an incision in the
  chest to gain access to the thoracic contents.
• Usually there is no requirement for gas insufflation as the
  operating space is held open by the rigidity of the thoracic
  cavity.
Endoluminal endoscopy

• Flexible or rigid endoscopes are introduced into hollow
 organs or systems, such as the urinary tract, upper or
 lower gastrointestinal tract, and respiratory and vascular
 systems
Perivisceral endoscopy
• Body planes can be accessed even in the absence of a natural
cavity. Examples are mediastinoscopy, retroperitoneoscopy and
retroperitoneal approaches to the kidney, aorta and lumbar
sympathetic chain.
• Extraperitoneal approaches to the retroperitoneal
organs, as well as hernia repair, are now becoming increasingly
commonplace, further decreasing morbidity associated with
visceral peritoneal manipulation.
• Other, more recent, examples include subfascial ligation of
  incompetent perforating veins in varicose vein surgery.
• Arthroscopy and intra-articular joint surgery
Orthopedic surgeons have long used arthroscopic access
to the knee and have now moved their attention to other
joints, including the shoulder, wrist, elbow and hip.
• Combined approach
The diseased organ is visualized and treated by an
assortment of endoluminal and extraluminal endoscopes
and other imaging devices.
Disadvantages of Open surgery
• In open surgeries , the surgeon must have a wound that is
  large enough to give adequate exposure for safe
  manipulation.
• This wound is often the cause of morbidity (infection,
  dehiscence, bleeding , herniation and nerve entrapment)
• The wound pain by itself prolongs recovery time and, by
  reducing mobility we increase the incidence of pulmonary
  atelectasis , chest infection and DVT.
• Mechanical and human retractors tend to inflict localized
  damage that may be as painful as the wound itself.
• Exposure of any body cavity to the atmosphere also
  causes morbidity through cooling and fluid loss by
  evaporation.
• Increased risk for post-surgical adhesions


• In handling intestinal loops, the surgeon and assistant
 disturb the peristaltic activity of the gut and provoke
 adynamic ileus
Advantages of Laparoscopic surgery
• Decrease in wound size
• Reduction in wound infection, dehiscence, bleeding,
     herniation and nerve entrapment
•   Decrease in wound pain
•   Improved mobility
•   Decreased wound trauma
•   Decreased heat loss
Limitations of Minimal access surgery
• To perform minimal access surgery with safety, the surgeon
must operate remote from the surgical field, using an imaging
system that provides a two-dimensional representation of the
operative site.
• The endoscope offers a whole new anatomical
landscape, which the surgeon must learn to navigate without
the usual clues that make it easy to judge depth.
• The instruments are longer and sometimes more complex to
  use than those commonly used in open surgery. This results in
  the novice being faced with significant problems of hand–eye
  coordination.
continued
• Usually (but not always) longer operating time


• Sometimes , it is better for the patient and to the surgeon
 to convert a Laparoscopic surgery to an open surgery

• if there is any intraoperative arterial bleeding
 ,haemostasis maybe very difficult to achieve
 endoscopically because the blood obscure the field of
 vision
Continued
• Loss of tactile feedback
Hand-assisted laparoscopic surgery is a well-developed
technique. It involves the intra-abdominal placement of a hand or
forearm through a minilaparotomy incision while
pneumoperitoneum is maintained. In this way, the surgeon’s
hand can be used as in an open procedure. It can be used to
palpate organs or tumors, reflect organs atraumatically, retract
structures, identify vessels, dissect bluntly along a tissue plane
and provide finger pressure to bleeding points while proximal
control is achieved. In addition, several reports have suggested
that this approach is more economical than a totally laparoscopic
approach, reducing both the number of laparoscopic ports and
the number of instruments Required and it is also easier to learn
than than total laparoscopic approaches)

• Problem in extraction of large specimens and resected tissue
Preoperative Evaluation
History
Physical examination
Informed consent

Preparation is very similar to that for open surgery and
aims to ensure that:
• The patient is fit for the procedure
• The patient is fully informed and has consented
• Operative difficulty is predicted when possible
History
1. Patient is fit to surgery or not (medical history )
2. Potential coagulation disorders or cardiac arrhythmias
3. Any previous abdominal surgeries (risk of adhesions )
4. Drug history
Physical examination
• Check the vital signs
• Full physical examination
• Presence of jaundice , abdominal scars ,palpable masses
  or tenderness
• If the patient obese or not (difficulty to maintain induced
  pneumoperitoneum )
Informed consent
• Make sure the patient understands the nature of the
 procedure , the risks and chance of conversion to open
 surgery .

								
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