surgery lecture - 12 endoscopy

8/14/2019 Surgery Lecture - 12 Endoscopy

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Endoscopy ranks as one of the mostEndoscopy ranks as one of the most

important technical advances inimportant technical advances in

medicine of the last few decades. Notmedicine of the last few decades. Notonly has it added a new precision toonly has it added a new precision to

gastrointestinal and pancreaticobiliarygastrointestinal and pancreaticobiliary

diagnosis, particularly when used indiagnosis, particularly when used in

conjunction with cytology or biopsy, butconjunction with cytology or biopsy, but

it has also been one of the earliestit has also been one of the earliesttools, along with interventionaltools, along with interventional

radiological techniques, in theradiological techniques, in the

advances of minimally invasive therapy.advances of minimally invasive therapy.


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Thereare two types of endoscopy

Rigid-Proctoscope

-Sigmoidoscope-Thoracoscopy-Cystoscope-Laparoscopy-Athroscopy

Flexible-Esofagogastroscopy

-Duodenoscopy

-Colonoscopy

-Sigmoscopy

-Bronchscopy


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The modern flexible endoscope hasThe modern flexible endoscope has

the following features:the following features:Light source in the handle with a fibreoptic bundle forLight source in the handle with a fibreoptic bundle forthe transmission of light to the area under investigation.the transmission of light to the area under investigation.

Viewing system Photons impacting on this areViewing system Photons impacting on this areconverted into a digital video signal which can then beconverted into a digital video signal which can then be

viewed on a screen. The video image can easily beviewed on a screen. The video image can easily bestored for use in teaching and can be enhanced bystored for use in teaching and can be enhanced byelectronic processing.electronic processing.

Control and manipulative elements which are stillControl and manipulative elements which are stillmechanical and allow the tip to be defected andmechanical and allow the tip to be defected andinstruments such as snares, stents, biopsy forceps,instruments such as snares, stents, biopsy forceps,balloons and baskets to be passed along a workingballoons and baskets to be passed along a workingchannel.channel.


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Preparing patient for examinationPreparing patient for examination

The patient must have an empty stomach; nothingThe patient must have an empty stomach; nothing

by mouth for 6 h beforehand is usually sufficient.by mouth for 6 h beforehand is usually sufficient.

Pharyngeal anesthesia to blunt the gag reflex isPharyngeal anesthesia to blunt the gag reflex is

achieved with benzocaine or lidocaine.achieved with benzocaine or lidocaine.The patient is also given intravenous sedation andThe patient is also given intravenous sedation and

is monitored during the procedure with bloodis monitored during the procedure with blood

pressure determinations, pulse oximetry andpressure determinations, pulse oximetry and

electrocardiography.electrocardiography.


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Procedure:Procedure:

Most endoscopists place the patient on his or herMost endoscopists place the patient on his or herleft side.left side.

Doctor hold the instrument in the left hand andDoctor hold the instrument in the left hand and

alternately manipulate the scope controls andalternately manipulate the scope controls andshaft with the right hand.shaft with the right hand.

After placing a bite block between the patientsAfter placing a bite block between the patientsteeth, the endoscope is inserted into his or herteeth, the endoscope is inserted into his or hermouth.mouth.

The tongue is followed down to its base where theThe tongue is followed down to its base where theupper larynx can be seen.upper larynx can be seen.


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The oesophagus is best entered underThe oesophagus is best entered undervision.vision.

The scope is guided posterior to theThe scope is guided posterior to the

arytenoid cartilages, where the viewarytenoid cartilages, where the viewbecomes obscured by the contractedbecomes obscured by the contractedcricopharyngeus muscle.cricopharyngeus muscle.

While maintaining gentle pressure againstWhile maintaining gentle pressure againstthe muscle with the scope, the patient isthe muscle with the scope, the patient isasked to swallow.asked to swallow.


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This maneuver allows ready passage of theThis maneuver allows ready passage of theinstrument into the upper esophagus.instrument into the upper esophagus.

If not, one should back up into the posteriorIf not, one should back up into the posterior

pharynx, suction out any saliva with the scope,pharynx, suction out any saliva with the scope,and try once more after the patient catches hisand try once more after the patient catches hisbreath.breath.

Keeping the gut lumen in the center of the fieldKeeping the gut lumen in the center of the field

of view the operator advances the scope distallyof view the operator advances the scope distallywith deflection of the tip and twisting of the shaftwith deflection of the tip and twisting of the shaftas necessary.as necessary.


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INDICATIONS.INDICATIONS.

Diagnostic esophagogastroduodenoscopyDiagnostic esophagogastroduodenoscopy

is especially valuable for evaluating upperis especially valuable for evaluating upper

gastrointestinal tumors, strictures, ulcers,gastrointestinal tumors, strictures, ulcers,

varices, and mucosal changes such asvarices, and mucosal changes such as

esophagitis and gastritis. It is less usefulesophagitis and gastritis. It is less useful

for judging functional or motility disordersfor judging functional or motility disorders

or extraluminal lesions.or extraluminal lesions.


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The major indications for diagnosticThe major indications for diagnostic

upper gastrointestinal endoscopy are:upper gastrointestinal endoscopy are:

(1) persistent upper abdominal pain or distress,(1) persistent upper abdominal pain or distress,especially if it is associated with symptoms or signsespecially if it is associated with symptoms or signssuggestive of serious disease (anorexia, weight loss,suggestive of serious disease (anorexia, weight loss,anemia);anemia);

(2)persistent symptoms of gastro-esophageal reflux(2)persistent symptoms of gastro-esophageal refluxdespite treatment;despite treatment;

(3)swallowing difficulties;(3)swallowing difficulties;

(4)persistent vomiting of unknown cause;(4)persistent vomiting of unknown cause;

(5)surveillance for upper gastrointestinal malignancy in(5)surveillance for upper gastrointestinal malignancy inhigh-risk patients;high-risk patients;

(6)evaluation of upper gastrointestinal bleeding of(6)evaluation of upper gastrointestinal bleeding ofunexplained iron deficiency anemia;unexplained iron deficiency anemia;

(7)evaluation of ulcers, strictures, and tumors found by a(7)evaluation of ulcers, strictures, and tumors found by abarium meal examinationbarium meal examination


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Indications for therapeuticIndications for therapeutic

esophagogastroduodenoscopy are:esophagogastroduodenoscopy are:

(1)cauterization of injection of bleeding peptic(1)cauterization of injection of bleeding pepticulcers (and occasionally vascularulcers (and occasionally vascularmalformations);malformations);

(2)injection sclerosis of esophageal varices that(2)injection sclerosis of esophageal varices that

have bled;have bled;(3)removal of foreign bodies or bezoars;(3)removal of foreign bodies or bezoars;

(4)removal of gastric polyps;(4)removal of gastric polyps;

(5)dilatation of esophageal strictures;(5)dilatation of esophageal strictures;(6)palliative treatment of malignant upper(6)palliative treatment of malignant uppergastrointestinal obstruction by dilatation, lasergastrointestinal obstruction by dilatation, laserfulguration, or intubation;fulguration, or intubation;

(7)placement of gastrostomy tubes.(7)placement of gastrostomy tubes.


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Contraindications toContraindications to

esophagogastroduodenoscopyesophagogastroduodenoscopy

Endoscope should be avoided if there is aEndoscope should be avoided if there is apossibility of a perforated viscus. If the stomachpossibility of a perforated viscus. If the stomachis not empty, little useful inspection is possible,is not empty, little useful inspection is possible,

and the risk of vomiting and aspirationand the risk of vomiting and aspirationpneumonia is great. A poor airwaypneumonia is great. A poor airwaycontraindicates upper gastrointestinalcontraindicates upper gastrointestinalendoscopy. Respiratory arrest may result if thereendoscopy. Respiratory arrest may result if thereis a marginal passage (for example, pharyngealis a marginal passage (for example, pharyngealtumor) combined with intravenous sedation, astumor) combined with intravenous sedation, aswell as partial occlusion and edema induced bywell as partial occlusion and edema induced bythe endoscope. Endoscope surgery should notthe endoscope. Endoscope surgery should notbe carried out if the patient is anticoagulated orbe carried out if the patient is anticoagulated or

has a coagulopathy.has a coagulopathy.


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ComplicationsComplications

Complications due to diagnosticComplications due to diagnosticesophagogastroduodenoscopy are uncommon.esophagogastroduodenoscopy are uncommon.Aspiration pneumonia may occur because of theAspiration pneumonia may occur because of thecombination of pharyngeal anaesthesia andcombination of pharyngeal anaesthesia and

instrumentation, especially in obtunded patients,instrumentation, especially in obtunded patients,or if there is active upper gastrointestinalor if there is active upper gastrointestinalbleeding. Although adverse cardiorespiratorybleeding. Although adverse cardiorespiratoryevents are rare, they may occur if the patient isevents are rare, they may occur if the patient isfrail or if sedation is excessive. Perforation andfrail or if sedation is excessive. Perforation and

bleeding are infrequent unless endoscopicbleeding are infrequent unless endoscopicsurgery is done. As is the case for colonoscopy,surgery is done. As is the case for colonoscopy,drug reactions, vasovagal reflex, bacteraemia,drug reactions, vasovagal reflex, bacteraemia,and superficial phlebitis are other less seriousand superficial phlebitis are other less serious

potential problems.potential problems.


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Erosion of stomachErosion of stomach


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Ulcers of stomachUlcers of stomach


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Ulcers of cardiac part of stomachUlcers of cardiac part of stomach


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BleedingBleeding


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Tumor ofTumor ofstomachstomach


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Varices of esophagus.Varices of esophagus.


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LaparoscopyLaparoscopy

The peritoneal cavity of a dog was examinedThe peritoneal cavity of a dog was examined

in 1902 by Kelling, using air insufflation andin 1902 by Kelling, using air insufflation and

the insertion of a cystoscope through thethe insertion of a cystoscope through the

abdominal wall. The first clinical use wasabdominal wall. The first clinical use was

described in 1912 by Jacobaeus, although itdescribed in 1912 by Jacobaeus, although it

was a further decade before a purpose-builtwas a further decade before a purpose-built

scope was in use by Kalk (1929) and the erascope was in use by Kalk (1929) and the eraof modern-day laparoscopy (peritoneoscopy)of modern-day laparoscopy (peritoneoscopy)

began.began.


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PROCEDURE (DIAGNOSTICPROCEDURE (DIAGNOSTIC

LAPAROSCOPY)LAPAROSCOPY)The patient is positioned supine on the operatingThe patient is positioned supine on the operatingtable. A general anaesthetic with muscle relaxationtable. A general anaesthetic with muscle relaxationis usually preferred, but it is possible to use localis usually preferred, but it is possible to use localanaesthetic and sedation with intravenousanaesthetic and sedation with intravenous

benzodiazepines. The Verres needle is introducedbenzodiazepines. The Verres needle is introducedvia a stab incision. This is usually subumbilical invia a stab incision. This is usually subumbilical inposition, but the presence of scars may influence theposition, but the presence of scars may influence theprecise location. The needle contains a spring-precise location. The needle contains a spring-loaded blunt probe, and compression of the springloaded blunt probe, and compression of the spring

against the skin retracts the probe to expose theagainst the skin retracts the probe to expose theneedle. Damage to intra-abdominal viscera can beneedle. Damage to intra-abdominal viscera can beminimized by holding up the anterior abdominal wallminimized by holding up the anterior abdominal wallwith one hand while inserting the needle with thewith one hand while inserting the needle with theotherother


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PROCEDURE (DIAGNOSTICPROCEDURE (DIAGNOSTIC

LAPAROSCOPY)LAPAROSCOPY)When the needle has passed through the abdominal wall theWhen the needle has passed through the abdominal wall theresistance falls and the spring pushes forwards the proberesistance falls and the spring pushes forwards the probecovering the needle. Free flow of normal saline solutioncovering the needle. Free flow of normal saline solutionthrough the needle confirms that the linea alba andthrough the needle confirms that the linea alba andperitoneum have been punctured. The abdomen is thenperitoneum have been punctured. The abdomen is then

insufflated with carbon dioxide, using approximately 2 to 3insufflated with carbon dioxide, using approximately 2 to 3litres for an adult. During insufflation, the intra-abdominallitres for an adult. During insufflation, the intra-abdominalpressure should not exceed 15 mmHg. The Verres needle ispressure should not exceed 15 mmHg. The Verres needle isthen withdrawn and the incision is enlarged to accommodatethen withdrawn and the incision is enlarged to accommodatethe laparoscope trocar, which is pushed down and back intothe laparoscope trocar, which is pushed down and back into

the pelvis. The end- or side-view telescope is then insertedthe pelvis. The end- or side-view telescope is then insertedand laparoscopy commenced. Biopsy forceps and aand laparoscopy commenced. Biopsy forceps and apalpating probe can be used in other, suitably placed stabpalpating probe can be used in other, suitably placed stabincisions through the anterior abdominal wall. This allows theincisions through the anterior abdominal wall. This allows theperitoneal contents to be inspected. Throughout theperitoneal contents to be inspected. Throughout theprocedure, carbon dioxide is continually insufflated at lowprocedure, carbon dioxide is continually insufflated at low

pressure.pressure.


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CONTRAINDICATIONSCONTRAINDICATIONS

There are few absolute contraindications to theThere are few absolute contraindications to the

procedure, but certain conditions should alert theprocedure, but certain conditions should alert the

surgeon to potential problems. Multiple scars makesurgeon to potential problems. Multiple scars make

introduction of the scope hazardous, and adhesionsintroduction of the scope hazardous, and adhesionsfrom repeated abdominal procedures may hinderfrom repeated abdominal procedures may hinder

the view within the peritoneum. Abdominal wallthe view within the peritoneum. Abdominal wall

sepsis may introduce intraperitoneal infection. Thesepsis may introduce intraperitoneal infection. The

procedure is not tolerated well in patients withprocedure is not tolerated well in patients withsevere pulmonary or cardiac problems, due to thesevere pulmonary or cardiac problems, due to the

intra-abdominal distension. Bleeding diatheses mayintra-abdominal distension. Bleeding diatheses may

result in body wall or intraperitoneal bleeding.result in body wall or intraperitoneal bleeding.


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COMPLICATIONSCOMPLICATIONS

To minimize complications, laparoscopy is aTo minimize complications, laparoscopy is aprocedure best performed by surgeons experienced inprocedure best performed by surgeons experienced inthe technique, in an operating theatre equipped withthe technique, in an operating theatre equipped withthe facilities to proceed to a laparotomy if necessary.the facilities to proceed to a laparotomy if necessary.Minor complications include abdominal wall bruising,Minor complications include abdominal wall bruising,subcutaneous emphysema, the development of asubcutaneous emphysema, the development of awound infection/hernia, and postoperative shoulderwound infection/hernia, and postoperative shoulderpain. Other complications are related to accidentalpain. Other complications are related to accidental

visceral damage and bleeding from vessel injury.visceral damage and bleeding from vessel injury.These problems should be noted at the time ofThese problems should be noted at the time oflaparoscopy and dealt with by prompt laparotomy iflaparoscopy and dealt with by prompt laparotomy ifnecessary. Mortality rates of 0.03 to 0.1 per cent arenecessary. Mortality rates of 0.03 to 0.1 per cent are

reported.reported.


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INDICATIONSINDICATIONS

In patients with localized peritonism, diagnosticIn patients with localized peritonism, diagnosticlaparoscopy is most commonly used in thelaparoscopy is most commonly used in themanagement of patients with acute right iliac fossamanagement of patients with acute right iliac fossapain. With the aid of a palpating probe insertedpain. With the aid of a palpating probe insertedthrough the anterior abdominal wall of the right iliacthrough the anterior abdominal wall of the right iliacfossa, the surrounding ileum and omentum may befossa, the surrounding ileum and omentum may bemanipulated away in order to see the appendix. In themanipulated away in order to see the appendix. In thecase of a retrocaecal or retroileal appendix, it may becase of a retrocaecal or retroileal appendix, it may be

impossible to visualize the target organ, but otherimpossible to visualize the target organ, but othersigns of acute inflammation may be noted.signs of acute inflammation may be noted.Alternatively, other causes of right iliac fossa pain mayAlternatively, other causes of right iliac fossa pain maybe apparent, and, if these require surgery, anbe apparent, and, if these require surgery, an

appropriate incision can be made.appropriate incision can be made.


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INDICATIONSINDICATIONS

The role of diagnostic laparoscopy in theThe role of diagnostic laparoscopy in themanagement of the patient with abdominal traumamanagement of the patient with abdominal traumais in conjunction with imaging techniques (CT andis in conjunction with imaging techniques (CT andultrasound scanning) and peritoneal lavage. Theultrasound scanning) and peritoneal lavage. Therelative importance of each is not establishedrelative importance of each is not establishedclearly, although aggressive use of laparoscopy inclearly, although aggressive use of laparoscopy inthis clinical situation may reduce the number ofthis clinical situation may reduce the number ofunnecessary laparotomies performed for minimal orunnecessary laparotomies performed for minimal or

moderate haemoperitoneum. The procedure can bemoderate haemoperitoneum. The procedure can beperformed in the accident and emergencyperformed in the accident and emergencydepartment under local anaesthesia withdepartment under local anaesthesia withintravenous sedation.intravenous sedation.


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Inflammation of appendixInflammation of appendix


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UUterusterus withwith myomamyomass nodenode


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AAbdominal pregnancybdominal pregnancy


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Inflammation ofInflammation ofovaryovary ((ovaritisovaritis))


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Inflammation of gallbladderInflammation of gallbladder


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Metastasis of stomach cancerMetastasis of stomach cancer

surgery lecture - 12 endoscopy

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