Presented by:-

Dr.Mohsin KhanPG Resident

MS (General Surgery)

GRMC Gwalior

Guide:-

Dr.Amit OjhaMS

Asst.Prof.Deptt of Surgery

GRMC Gwalior

A three bladed speculum was found in the ruins

of Pompeii*.

*A roman town buried by a volcano eruption

near modern Naples, Italy - 79 AD).

The first description dates to Hippocrates in The first description dates to Hippocrates in Greece, for use of a speculum to visualize Greece, for use of a speculum to visualize the rectum (460–375 BC).the rectum (460–375 BC).

1910: Swedish internist; first thoracoscopic diagnosis with a cystoscope in a human subject.

Treatment of a patient with tubercular intra-thoracic adhesions.

The Possibilities for Performing Cystoscopy in The Possibilities for Performing Cystoscopy in Examinations of Serous Cavities. Examinations of Serous Cavities. Münchner Medizinischen Münchner Medizinischen Wochenschrift,Wochenschrift, 1911 1911

1911 : First laparoscopy at Johns Hopkins

12mm proctoscope into epigastric incision on one of Halstead’s patients to stage pancreatic cancer

Bernheim called his procedure ‘organoscopy’

Findings confirmed on laparotomy

1920: Zollikofer discovered the benefit of CO2 gas for insufflation

1938: Janos Veress developed a spring loaded needle for the induction of pneumoperitoneum.

After World War II, the development of fiberoptics represented an important step forward for endoscopy

1966: Hopkins rod lens scope & cold light

1974: Dr Harrith M Hasson, MD working in Chicago, proposed a blunt mini-laparotomy which permitted direct visualization of the trocar entrance into the peritoneal cavity. It is popularly known today as Hasson‘s technique.

1985: Dr. Muhe (Prof Dr Med - Böblingen, Germany) performed the first successful laparoscopic

cholecystectomy in a human.  However, this was not

well publicized until years later. The German Surgical

Society rejected Mühe in 1986 after he reported that he

had performed the first laparoscopic cholecystectomy.

Minimal access surgery is a marriage of modern technology and surgical innovation that aims to accomplish surgical therapeutic goals with minimal somatic and psychological trauma

Laparoscopy Thoracoscopy Endoluminal endoscopy Arthroscopy and intra-articular joint surgery

Combined approach

DIAGNOSIS

Gallstone

Appendicitis

Hernia

Adhesions

Perforated ulcer

Hiatus Hernia

OPERATIONCholecystectomyAppendicectomyHernia repairDivision of

adhesionsClosure of

perforationHiatus hernia

repair.

DIAGNOSIS

Colorectal carcinoma

Caecal carcinoma

Colonic carcinoma

Gastric carcinoma

Oesophageal carcinoma

OPERATION

Anterior resection/ APR

Right Hemicolectomy

Left/Sigmoid Colectomy

Gastrectomy

Oesophagogastrectomy

Diagnosis

Crohn’s Disease

Diverticulitis

Rectal Prolapse

Benign renal disease

Gastric Obstruction

Some Splenic disorders

The list is endless!!!

OperationBowel resectionBowel resectionRepair of ProlapseNephrectomyBypassSpleenectomy

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.

FOR THE HOSPITAL Initial capital costs to establish laparoscopic

surgery in the order of Rs 10 - 20 lacs

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.

Open Surgeon Fast Hand is as good as eyes Dissection precedes Ergonomics: Optional

Laparoscopic Surgeon Slow and steady Stop when you don’t see Haemostasis precedes Ergonomics: Vital

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.

Redesign of instruments for laparoscopic use. Instruments for open surgery in general 6 –

10” in length built around a box joint. Laparoscopic instruments in general 15 – 18”

in length with an articulated connecting rod between handles and scissor blades, jaws etc.

Camera

Light Source

Insufflator

TV Monitor

Telescopes

Light Guide Cable

Apart from the insufflator the system will work better if all the components are from the same company as one piece talks to another

These can be single chip or 3 chip(red,green,blue).

CHIP: this is also called a charged coupled device in short, CCD.

These are flat silicone wafers with a matrix, a grid of minute image sensors called pixels.

White balance and sometimes black balance

Halogen or Xenon, cold light.

Brightest to darkest measured in units of decibels.

White balance by making sure white is correct then all the colours through the spectrum are correct.

CO2 is used because this has the same refractive index as air, so doesn’t distort the image and is non combustible.

Intraabdominal pressure run between 10 and 13 mmhg.

Use disposable filter and tubing for each patient.

High flow insufflators (35 litres) output determined by size of outlet.

Ensure you know how to change a cylinder and were they are stored.

Usually a 20” screen. HD is better. You can use a standard TV

but it must be run through an isolated transformer.

Horizontal resolution is the number of vertical lines.

Vertical resolution is the number of horizontal lines

More lines of resolution, better detail of picture.

Different diameters Fibre light cable Autoclavable Don’t bend to acute angle as will

break fibres. Check when you plug them in are

all the fibres are okay. Condensers

Single use Reusable Need an ultrasonic washer to effectively

clean them, not for telescopes. Don’t put 5mm cannulated instruments into

a bench top autoclave that does not have a vacuum: vacuum is required to remove all air form lumen of instrument.

Ports 5 and 10mm are the most common, make sure the right trocar is in port and is it sharp.

1938 - Janos Veress, of Hungary, developed the spring-loaded needle. to perform therapeutic pneumothorax (TB).

Made of surgical stainless steel with a single trap valve. 2mm diameter x 80mm length

It consists of an outer cannula with a bevelled needle point for cutting through tissues.

ABDOMINAL ACCESS INSTRUMENTSABDOMINAL ACCESS INSTRUMENTS

Open Technique Closed

Technique

Hasson Cannula Veress Needle

Trocar Sheath

assemblies

Controlled pressure insufflation of the Controlled pressure insufflation of the peritoneal cavity is used to achieve the peritoneal cavity is used to achieve the necessary work space for laparoscopic necessary work space for laparoscopic surgery. surgery.

Automatic insufflators allow the surgeon to Automatic insufflators allow the surgeon to preset the insufflating pressure, and the preset the insufflating pressure, and the device supplies gas until the required device supplies gas until the required intra-abdominal pressure is reached. intra-abdominal pressure is reached.

tro-car - [Fr., troisis, three +carre,

side] noun

a sharp-pointed surgical instrument

fitted with a cannula and used

especially to insert the cannula into

a body cavity

cannula - [L., dim of canna,reed] noun

a tube that is inserted into a cavity

by means of a trocar filling it’s lumen

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)

Types:Cutting

Pyramidal tipped Flat blade

Noncutting Pointed conical Blunt conical Optical

Come in varying sizes, laparoscopes usually 5mm or 10mm.

Diagnostic 3mm scope available. Made up of a rod and lens system. Bundles of fibres, incoherent carry light

and coherent carry image. Wide range of angles available 0, 30, 45

degree are fairly standard. All laparoscopes are autoclavable and can

go through sterilisation, no ultrasonic bath required.

Endo- chameleon- extra long for Bariatric patients.

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

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.

Atraumatic

KELLY atraumatic

Atraumatic, with hollow jaws

MANGESHKAR Grasping Forceps, serrated

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.

HOOK SCISSORS, single HOOK SCISSORS, single action jawsaction jaws

METZENBAUM SCISSORS, METZENBAUM SCISSORS, curved, length of blades 12-17 curved, length of blades 12-17 mm, widely used as an mm, widely used as an instrument for mechanical instrument for mechanical dissection in laparoscopic dissection in laparoscopic surgery. surgery.     

STRAIGHT SCISSOR STRAIGHT SCISSOR can give can give controlled depth of cutting controlled depth of cutting because it has only one moving because it has only one moving jaw. jaw.

Thoracic triangle

Pelvic triangle

1 2

34

Each quadrant must be addressed from frontal as well as lateral positions.

yz

x

Working against the camera and ‘blind spots’

“Dueling swords” phenomenon (scissoring effect)

To avoid iatrogenic injuries.

Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182

(adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.)

Iliohypogastric n.

Ilioinguinal n.

Incision line/trocar sites vs. nerve distribution

Epigastric a.

Trocar site Pfannenstiel incision

Straight Line principle

Triangulation Manipulation angle Elevation angle Low lying table Gaze down view

Surgeon

PathologyMonitor

Monitor

S

C

R

L

P

Azimuth Angle;Angle b/n scope and working hands

Manipulation Angle;angle b/n working hands

30-45 degree60-90 degree

1. Manipulatation angle: 60 degree2. Azimuth angle: Equal/30 degree each3. Elevation angle: 60 degree

Ideal relaxed stature Tiring

-straight head, in the axis of the trunk, without rotation or extension of the cervical spine;- shoulders in a relaxed and neutral position;- arms alongside the body- elbows bent to 70 to 90 degrees- forearms in an horizontal or slightly descending axis- -hands pronated (physiological resting position);- hands and fingers lightly grip the handles/handpiece

•Waist line table•Gaze down view of monitor•Straight line principle•Triangulation

Trocar distance from the target organ depends upon the size of the patient.

Individual trocars can be moved closer to the target along an

axis line.

Additional trocars can

be added along

thesemicircular

line.

COMPLICATIONS OF COMPLICATIONS OF LAPAROSCOPIC SURGERIES LAPAROSCOPIC SURGERIES

1. Anaesthetics Complications

2. Complications due to pneumoperitonium

3. Surgical complications

4. Diathermy related injuries

5. Patients factors related complications

6. Post operative complications

COMPLICATIONS COMPLICATIONS Anaesthetic Complications : 1. Inadequate Muscle Relaxation –

Contraction of muscle during procedure

Difficulty in Causes pain during portPneumoperitoneum insertion

Management – - Endotracheal intubation - Pharmacological neuromuscular blockade - Positive pressure ventilation

Anaesthetic Complications : 2. Mask hyper ventilation Prior to induction 100% oxygen is given by

mask ventilation

Hyperventilation

Distended stomach

Respiratory Dysfunction Liable to injury during port inser. Orveress needle inser.

Management – - Nasogastric tube prior to surgery.

Anaesthetic Complications : 3. Air Embolism

CO2 used for pneumoperitonium

Gets absorbed into circulation

Embolus may form and block pulmonary circulation

• Loud and clear murmur heard in (R) atrium and (R) ventricle (Mill-Wheel murmur)

Management – - Direct intracardiac insertion of needle - Central venous catheter.

Management - Continuous I/V access - Emergency cart with all resuscitative drugs and

defibrillator. One should be prepared with – - Oxygen - Suction - Bag and mask ventilation - Oral and nasal pharyngeal airway, ET tubes of

various sizes. - Sphygmomanometer - Electrocardiograph - Pulse oxymeter

COMPLICATIONS DUE TO PNEUMOPERITONIUMCOMPLICATIONS DUE TO PNEUMOPERITONIUM CO2 pneumoperitonium

(a) Gas specific effects (b) Pressure Specific Effects 1. Respiratory Acidosis Excessive Pressure on IVC2. Hypercarbia

Reduced VR

Reduced CO

Rapid stretch of peritoneal membrane

Vasovagal response

Bradycardia, occasionally hypotension

Management -

• Desufflation of abd.

• Vagolytic (Atropine)

• Adequate volume replacement

Respiratory Dysfunction

Increased pressure pneumoperitonium

Transmitted directly across paralysed diaphragm to thoracic cavity

Increase Central venous pressure & inc. filling pressure of (Rt) and (Lt) sides of heart

Management : • Keep intraabdominal pressure under 15 mm Hg

Effects on renal system

Increased intraabdominal pressure

Reduced RBF, Reduced GFR Inc. ADH activity

Reduced Urine output Inc. free water absor.

Inc. plasma renin activity

Inc. Na+ retention

Management : • Adequate volume replacement at maintenance rate.

Pneumothorax

• Due to true diaphragmatic hernia. • Without any apparent cause. Diagnosis - • Presence of rapidly falling Oxygen saturation or

PO2 together with difficult ventilation and decreased breath sounds.

Management – • Immediate needle thoracostomy. • Aspiration • Chest radiograph • Placement of chest tube

Subcutaneous and Subfascial Emphysema and Edema

Improper insertion of veress needle Manipulation of instruments often loosens the parietal

peritoneum surrounding the instruments portal of exit into the peritoneal cavity.

CO2 then infiltrates the loose areolar tissue of the body

Subcutaneous and sub fascial emphysema

* It rapidly resolves within 2 – 4 hours postoperatively.

SURGICAL COMPLICATIONS SURGICAL COMPLICATIONS Injury to Viscus : Stomach -Hyperventilation by Mask

Distended stomach

May be injured with trochar or needle Diagnosis - • Laparoscopic view of inside of stomach Management – • Extend trocar incision into a minilap. for a two

layer closure.• Laparosocpically

- Pursestring suture or a figure of 8 suture in the seromuscular layer surround the defect.

- Nasogastric tube drainage for two days.

Injury to Viscus : Bowel - May be injured due to trocar or veress needle

If due to veress needle it is managed conservatively

Diagnosis - • The emanation of foul smelling gas through

pneumo-peritoneal needle is a helpful diagnostic sign.

• There may be GI contents at the tip of needle.

Management – • Mini laprotomy and repair of perforation. • Laparoscopically it may be sutured of

laparoscopic stapler (ENDO-GIA) can be used. • Colostomy

Injury to Viscus : Small Bowel Perforation - Most often during

insertion of umblical or lower quadrant trocars

Usually recognized later in the procedure

If adhesions are not freed from anterior abdominal wall perforation may not be recognized

Management – • One should consider higher primary site if

adhesions are found through umblical port.• Perforation repaired transversally • If injury is free of adhesions bowel can be

withdrawn through 10 mm trocar tract and repaired.

Injury to Viscus : Bladder - Injury caused by second puncture trocar

usually . Diagnosis : Appearance of gas and blood in Foley’s

catheter bag. Management – • Early detection is important. • Place an indwelling catheter for 7-10 days and

prophylactic antibiotics - If defect is larger.

Repaired by a figure of 8 suture through muscularis of bladder & second suture to close peritonium

* A water tight seal should be documented by filling bladder with indigo carmine dye solution.

Injury to Viscus : Ureter - May be injured in adenexal surgeries. • Thermal injury will result in ureteral narrowing and

hydroureter. Management – • Placement of ureteric stent for 3 – 6 weeks.

Incision Hernia : • Failure to close facial defects from incisions for

secondary trocars. • Incised fascia should be located with help of skin

hooks and repaired.

Vessel Injury : • Larger vessels may be injured by trocar or veress

needle.• CO2 peritoneum may tamponade a large vessel

injury. • When pressure normalizes it starts bleeding. Management – • Examine the course of large vessels. • Overlying peritoneum is opened with laproscopic

scissors or a CO2 laser.

Hematoma evacuated by alternate suction and irrigation.

* Laprotomy is required if hematoma is expanding or persistent bleeding.

Vessel Injury : Epigastric Vessels – • Deep epigastric vessels most frequently injured in

laproscopic hysterectomy. Management – By Tamponade – • By Foley’s catheter• Bipolar coutery• Needle suturing • Small haemostat (Mosquito clamp)Ovarian or uterine vessels – • Injured during laproscopic hysterectomy Management – • Bipolar desiccation • Ureter must be identified before desiccation.

DIATHERMY RELATED INJURIESDIATHERMY RELATED INJURIESDue to – • Inadvertent activation of the diathermy

pedal. • Faulty insulation

Cautery should be used under vision Injuries – • Thermal necrosis of organs. • Inadvertent organ ligation. • Unrecognized haemorrhage.

PATIENT’S FACTORS RELATED COMPLICATIONSPATIENT’S FACTORS RELATED COMPLICATIONS

• Obesity • Ascites • Organomegaly – organ damage • Clotting problems – haemorrhage

POST OPERATIVE COMPLICATIONS • Concealed injury to organs • Delayed feacal fistula • Port site metastasis • Residual air (Referred chest or shoulder pain)

CONTRAINDICATIONS CONTRAINDICATIONS

Absolute : • Generalized peritonitis • Intestinal obstruction • Clotting abnormalities • Liver cirrhosis • Failure to tolerate general anesthesia • Uncontrolled shock Relative : • Multiple abdominal adhesions • Organomegaly • Abdominal aortic aneurysm

Robotics SILS NOTES Trocarless laparoscopy ENDOBARRIER

Leonardo da Vinci developed one of the first robots in 1495 – an armored knight for the purposes of entertaining royalty.

Surgeon operates from a 2D image

Straight, rigid instruments (limited range of motion)

Instrument tips controlled at a distance

Reduced dexterity, precision & control

Unsteady camera controlled by assistant

Dependent on assistant for surgical support through accessory port

Greater surgeon fatigue

Makes complex operations more difficult

AESOP (Automated Endoscopic System for Optimal Positioning)

- Voice activated mechanical arm

- Steadier than human, never tires

da Vinci®

- FDA approval in 2002

- Laparoscopic instrumentation controlled by

the surgeon, positioned remotely at a console

Defense Advanced Research Projects Agency (DARPA) for military research of remote battlefield surgery

Cholecystectomy performed remotely via telesurgery from 300 miles away

First robotic prostatectomy performed in 2001

State-of-the-art robotic technology

Surgeon in control Assistant has direct access

Surgeon directs precise movements of instruments in the slave unit using console controls.

What is the What is the da Vincida Vinci®® Surgical System?Surgical System?

Laparoscopic instruments are rigid with no wrists

EndoWrist® Instrument tips move like a human wrist

Allows surgeon to operate with increased dexterity & precision. No tremor

Expensive

- $1.4 million cost for machine

- $120,000 annual maintenance contract

- Disposable instruments $2000/case

Steep surgical learning curve Loss of tactile feedback Increased staff training/competence Increased OR set-up/turnover time!!

Past Present

SILS – Single Incision Laparoscopic Surgery SSA – Single Site Access SPA – Single Port Access SAS – Single Access Site SPL – Single Port Laparoscopy LESS – Laparo Endoscopic Single Site Surgery TUES – Trans Umbilical Endoscopic Surgery

Urology Renal transplant Cholecystectomy Gastric band surgery Colectomy

Ergonomically difficult ?!

Training !

No surface incision Reduced surgical site infection Reduced visible scarring Reduction in pain analgesics Quicker recovery time Reduction in hernias, adhesions Advantages in the morbidly obese

Video-endoscope entering through the posterior vaginal fornix

NOTES - Transgastric

Courtesy of N Reddy, Hyperbad India 2005

It has not changed the nature of disease

The basic principles of good surgery still apply,including appropriate case selection, excellent exposure,adequate retraction and a high level technical expertise

If a procedure makes no sense with conventional access, it will make no sense with a minimal access approach

The cleaner and gentler the act of operation, the less the patient suffers, the smoother and quicker his convalescence,the more exquisite his healed wound.

Berkeley George Andrew Moynihan