Dr.Saifuddin AhmedIMO

Department of surgery, Unit 1Chittagong Medical College

Hospital

Contents

1. What is laparoscopy and its applications2. History3. Instruments ( details)4. Indications and contraindications 5. Physiological changes 6. Port of laparoscopy 7. Complications during operation8. Commonly practiced laparoscopic surgeries 9. Some pictures of laparoscopic appendicectomy

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.

TYPES1 Intraperitoneal2 Extraperitoneal3 Abd wall retraction (gasless laproscopy)4 Hand assisted (Hassans tech.)

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

INSTRUMENTS USEDZero degree laparoscopeCold light source (Halogen and Xenon lamp)Camera ( 3chip camera commonly used with high resolution Video monitor to display imagesCO2 insuffulator Long fine dissectors Hooks and spatulas with cautery for dissectionsClip applicators Needle holdersVeress needleTrocars of different sizes – 10mm, 5mmSuction irrigation apparatusReducers to negotiate smaller instruments through larger ports

TelescopeThere 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

TrocarThe 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

Optic CablesThese 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.

Dissecting & Grasping Forceps Atraumatic

KELLY atraumatic

Atraumatic, with hollow jaws

MANGESHIKAR Grasping Forceps, serrated

Laparoscopic Hook It is used to separate adhesions, Used for diathermy purpose,

To give traction to any organ.

Scissors HOOK SCISSORS, single action jaws

METZENBAUM SCISSORS, curved, length of blades 12-17 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. .

General instruments Reusable three-piece design

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.

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 )

Gases used to create pneumoperitoneum :

•Air•O2•CO2 : most common•N2O : prefered for patients with cardiac disease•He, Ne, Ar ( new )

Why CO2 is commonly usedto create pneumoperitonium ?

Readily availableCheaperEasily absorbed by tissuesQuickly released via respiration

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

Ryle’s tube and foley’s catheter are essential before insertion of the trocars

Pneumoperitoneum is created using veress needle through umbilical incision

PHYSIOLOGICAL CHANGES

Physiological changes

position

co2

pneumoperitoneum

Physiologic changes due to pneumoperitoneum

CO2 causes hypercarbia, acidosis and hypoxiaPneumoperitoneum exerts pressure on the IVC,

decreases the venous return and so the cardiac outputIncrease the arterial pressure Compromises the respiratory function by compressing

over the diaphragm imparing the pulmonary compliance

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

Basic Diamond Concept of Port Position

Mainly two port 5mm and 10mm portLaparoscope 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

Basic Diamond Concept of Port Position

Port position for appendectomy

Port position for cholecystectomy

(10mm)

(5mm)

(5mm)

Commonly practiced laparoscopic surgeries

Laparocopic cholecystectomyLaparoscopic appendicectomy

Laparoscopic inguinal hernia repair

Laparoscopic hysterectomy

Less commonly practiced laparoscopic surgeries

Laparoscopic perforation repairLaparoscopic splenectomyLaparoscopic vagotomy and

gastrojejunostomyLaparoscopic urologic surgeries

Diagnostic laparoscopyNeedle 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

CONTRAINDICATIONS

1. Absolute - none2. Relative i) severe COAD ii) recent MI iii) ventriculoperitoneal shunts iv) Increased ICT v) extensive organomegaly

vi) CHF

Advantages of laparoscopic surgery 1. Less post operative pain2. Faster recovery time3. Shorter hospital stay4. Smaller scars5. Less internal scarring6. Less risk of wound infection and incisional hernia7. Better visualization of anatomy

Laparoscopic Surgery

Laparoscopic appendicectomy

Complications1. Insertion Related :

o Major vascular injuryo GI Injuryo Bladder injuryo CO2 embolismo Abdominal wall haemorrhage

2. Post Insertional : GI perforations Laceration & bleeding from solid organs Abdominal wall hernia

3. Pneumoperitoneal Related: CO2 embolism Hypercarbia Respiratory acidosis Subcutaneous emphysema Renal failure Venous thrombosis Pneumothorax