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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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