6234855 laparoscopic abdominal surgeries
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LAPAROSCOPIC ABDOMINAL SURGERIES
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Laparoscopic surgery! Minimal Access (Keyhole) Surgery
Laparoscope = long, thin tube with a camera lens & light that allows
the examination of organs inside the abdominal cavity by providing a
clear magnified view on a TV monitor that therefore allows operations to perform the same operation that surgeons can do through a large incision
allows many common operations on the colon and rectum to be performed
through small incisions (usually less than one inch in length).
Laparoscopic and thoracoscopic surgery
belong to the broader field of endoscopy
WH AT IS LAPAROSCOPIC SURGERY
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The key element in laparoscopic surgery is the use of a laparoscope : a
telescopic rod lens system , that is usually connected to a video camera (single chip or three chip). Also attached is a fiber optic cable system connected to a 'cold' light source
(halogen or xenon), to illuminate the operative field, inserted through a 5 mm
or 10 mm cannula or Trocar to view the operative field.The abdomen is usually insufflated with carbon di oxide gas to create a
working and viewing space.The abdomen is essentially blown up like a balloon (insufflated), elevating
the abdominal wall above the internal organs like a dome.
The gas used is CO2, which is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-
flammable, which is important because electrosurgical devices are commonly
used in laparoscopic procedures.
KEYS OF LAPAROSCOPIC SURGERIES
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E arly 1800 ² CYSTOSCOP E S US ED
1806-Philip Bozzini, of AUSTRIA, aluminium tube used to visualise
the genitourinary tract. The tube, illuminated by a waxcandle, had fitted
mirrors to reflect images. He called this instrument "Lichtleiter".
1853-Antoine Jean D esormeaux, French surgeon first
introduced the Lichtleiter ( Simple tube about candlelight) into a patient.
Considered as the "Father of E ndoscopy´ lead to develop Cystoscopes
1876-Maximilian Nitze, modified E dison's light bulb invention and created the first optical endoscope with built-in electrical light bulb as
the source of illumination.
(All instruments used only for genito-urological procedures
HISTORY OF LAPAROSCOPY
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E
ARLY 20 th
C E
NTURY ² LAPAROSCOPY INTRO D
UC ED
1901-Georg Kelling of Germany, first experimental laparoscopy, using
a cystoscope to peer into the abdomen of a dog after first insufflating
it with air and done lap cholecystectomy.
HISTORY OF LAPAROSCOPY Contd
1911-Jacobeus of SW EDE N 1st human laproscopy
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1938-Veress, of Hungary, developed the spring-loaded needle. Adapted Modification of ´Veress needleµ used to achieve
pneumoperitoneum
1978-Hasson blunt mini-laparotomy which permits direct
visualization of trocar entrance into the peritoneal cavity
HISTORY OF LAPAROSCOPY Contd
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1960-1970-Semm ´Father of modern laproscopic surgeryµ
D eveloped automatic insufflators and instruments and carried out 1st lap appendicectomy.
1987-Phillipe Mouret, performed the first laparoscopic
cholecystectomy in Lyons, France
Sir Alfred Cuschieri Laparoscopic Principle:
Normal trauma of access > intrinsic trauma of procedure
HISTORY OF LAPAROSCOPY Contd
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Fibreoptic scopes
Rod lens system Fiber Optic cables Light sources & video systems
New Miniaturized Aspirator
D issecting forceps Grasping instruments
Scissors Clip applicator s
Staples
Sutures / needles Needle holder Cautery (mono & bi polar)
New vascular control
Harmonic Scalpel Ligatures
INSTRUMENTS OF MODERN LAPAROSCOPY
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ABDOMINAL ACCESS INSTRUMENTS
Open Technique
1. Hasson Cannula
Closed Technique 1. Veress Needle
2. Trocar Sheath
3. assemblies
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Less pain than laparotomy
E xposure without skin retraction
Less superficial trauma
Smaller incision & Smaller scar
Faster recovery
Shorter hospital stay (2-4 days)
Precise & Less dissection through tissue layers.
Fewer wound infections
Long term pain has also been shown to be less common after laparoscopy
ADVANTAGES OF LAPOROSCOPIC SURGERIES
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Laparoscopic cholecystectomy Laparoscopic fundoplication (Nissen·s)
Laparoscopic adrenalectomy
Laparoscopic obesity surgery E xcisional surgery, no r
reconstruction, trauma access >trauma of excision etc...
Laparoscopic appendicectomy
Laparoscopic colectomy
Laparoscopic inguinal hernia repair Laparoscopic splenectomy
Laparoscopic nephrectomy
Gold Standard Abdominal Surgeries
Co-Gold Standard Abdominal Surgeries
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I. Intra-operative
Access/Patient positioning/Number of ports Loss of tactile feedback: traction & c/traction The camera never lies: Off camera injury!
Control of major bleeding! D iathermy issues Medico legal & conversion
PROBLEMS WITH LAPAROSCOPIC SURGERIES
II. Postoperative
Musculoskeletal pain due to positioning Off camera injury ² delayed presentation.Referred pain ² shoulder tip Wound haematomas & bruising D VT/P E
Port site hernias
Longer procedure
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Tachypnoea
shallow breathing suppression of the cough reflex Atelectasis
Respiratory infections Bleeding
Infection Injury to other organs such as blood vessels, the ureter (carries
urine from the kidney to the bladder), and the urinary bladder
A leak from the connection that is made between the two ends of the intestine
DISADVANTAGES OF LAP SURGERIES
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Surgery on the large intestine can be performed
in two ways
1. OPEN (a single, large conventional incision)
2. LAPAROSCOPIC ( several very small
incisions)
SURGERY OF THE COLON AND RECTUM
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Conventional (Open) Colon and Rectal Surgery
In open (conventional) surgery, a large incision is made in the middle of the
abdomen (belly) to allow the surgeon good visualization and access to the colon
and rectum.
The incision must be large enough for the doctor to be able to get his hands
into the abdomen.
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LAP HOLES FOR COLON SURGERIES
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The operation involves removing most or even all of the colon, in which case a reservoir is created from the end of the small bowel so that you can still have a bowel movement
(defecate) the normal way.
This is a complex operation, even as an open procedure, and only a few surgeons perform this laparoscopically.
LAPAROSCOPIC COLON AND RECTAL SURGERIES
Laparoscopic Resection for Polyps
Operation is almost always recommended after 2 attacks that result in
hospitalization, or after one attack in very severe cases.
A laparoscopic approach may be possible after the inflammation has settled, but is rarely indicated for an emergency operation.
LAPAROSCOPIC RESECTION OF DIVERTICULITIS
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If an operation is needed to remove a large polyp, generally the segment or portion of
the colon where the polyp is located is removed
If the polyp is at high risk of already containing a cancer, a laparoscopic approach may not be appropriate.
LAPAROSCOPIC RESECTION OF COLORECTAL POLYPS
LAPAROSCOPIC RESECTION FOR CROHNS DISEASE
Patients with Crohn·s disease have a 50% lifetime risk of needing an operation at some point in their lifetime. After the, there is again a 50% risk of needing another operation.
The commonest site of Crohn·s, at the end of the small intestine, is also the easiest to perform
laparoscopically. Some surgeons now consider this approach to be their first choice.
The laparoscopic approach may reduce the formation of adhesions, and thus allow subsequent operations to be performed laproscopically too.
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LAPAROSCOPIC RESECTION FOR ULCERATIVE COLITIS
In ulcerative colitis the entire colon has to be removed.
At the end of the operation, the incisions and
ileostomy look like this.
After 3 months the ileostomy is closed, and
the final incisions are barely visible after healing.
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How is Laparoscopic Colon Resection Performed?
The surgeon enters the abdomen by placing a canula (a narrow tube-like instrument) into the abdomen (belly) through a small incision ( ¼ ² ½ inch)
Carbon D ioxide (CO2) gas is pumped into the abdomen through the port (canula) to ´puff-upµ or inflate the belly, making working room for the surgeon.
A laparoscope (a tiny telescope connected to a video camera) is placed through the canula, and allows the surgeon to see a magnified lighted view of the internal organs on a TV monitor.
2-4 other canulas are inserted to allow use of special instruments to work inside the
abdominal cavity (belly)
If a portion of the colon is removed, one of the small canula incisions is slightly enlarged to permit removal of the tissue.
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How is Laparoscopic Colon Resection Performed?
This shows the ́ canulasµ or tubes that are inserted to allow special surgical
instruments to be used inside the abdomen.
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Schematic diagram of location of the instrument and camera portals to perform laparoscopic surgery on the colon or rectum.
How is Laparoscopic Colon Resection Performed?
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Blood clot in the veins of the leg or the lungHernia
Blockage or obstruction of the bowel Narrowing of the connection which is made
between the two ends of the bowel Spread of cancer (if that is what the surgery is for)
to one of the incisions Injury to the spleen D eath
RISKS OF COLON LAP SURGERIES
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Grasping andDissectingInstruments
Telescopeand Camera
GALL BLADDER LAP SURGERIES/ LAP CHOLECYSTECTOMY
Lap Holes for gall bladder surgeries
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This picture shows how the laparoscopic operation is performed. The camera that is connected to the
telescope which is inside of the abdomen (belly) projects the picture onto the large TV. The surgeon then uses this picture in combination with small instruments to remove the gallbladder
GALL BLADDER LAP SURGERIES/ LAP CHOLECYSTECTOMY
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LAP CHOLESYSTECTOMY
DELIEVERING THE GALL BLADDER
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Injury to the bile duct
njury to the intestine of one of the adjacent organs
Narrowing of the bile duct
Bleeding
Infection
Hernia Leakage of bile into the abdominal Cavity
Spillage of stones into the abdominal cavity Missing stones in the bile duct
Bowel obstruction (blockage) from scar tissue
Blood clot in the veins of the leg or in the lung
Possible complications of gallbladder surgery
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75% were significantly better after laparoscopic cholecystectomy when compared to open surgery
Significantly lower incidence of atelectasis and better oxygenation
D iaphragmatic function is also significantly impaired after Laparoscopy
Post-op respiratory function recovery is slower in elderly, obese, COP D and smokers, but less
impaired than after laparotomy
Reduced Recovery Time
Reduced post operative ileus
Reduced fasting and IV infusion
Hospital stay significantly reduced
Improved Cosmetic Appearance
Improved visualisation of the Operative field
ADVANTAGES OF LAP CHOLECYSTECTOMY
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Physiological consequences
Pneumoperitoneum Raised intra-abdominal pressure Operative position of the patient Technical difficulty of the procedure Unsuspected visceral injury D ifficulty in evaluating amount of blood loss Gas embolism / Pneumothorax / Surgical E mphysema
Vessel trauma
Cardiovascular Effects
Raised intra abdominal pressure Hypercarbia Intra-operative position of the patient D uration of the procedure
Rate and volume of gas used for insufflation Age of the patient coexistent cardiopulmonary disease Intravascular volume status of the patient (9)
DISADVANTAGES OF LAP CHOLECYSTECTOMY
intestinal & vascular injuries
Lap chole mortality 0.1 - 1 per 1000
Conversion to laparotomy 1% , bowel perforation CB D injury & haemorrhage Large vessel injury Retroperitoneal haemorrhage Gas embolus
GI Tract injury
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InguinalInguinal
HerniaHernia
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APPENDIX LOCATIONS
LAP APPENDICECTOMY
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APPENDICITISDISSECTION OF MESOAPPENDIX
LAP APPENDICECTOMY
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DIVIDING THE APPENDIX
Stapled
Looped
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COMPLICATIONS
Anesthetic Complications :
1. Inadequate Muscle Relaxation Contraction of muscle during procedure Contraction of muscle during procedure
D ifficulty D ifficulty in in Causes Causes pain pain during during port port
Pneumoperitoneum Pneumoperitoneum insertion insertion Management - E ndotracheal intubation - Pharmacological neuromuscular blockade
- Positive pressure ventilation
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COMPLICATIONS OF LAPAROSCOPIC COLECTOMY
1. Bowel Injuries :
- The viscra and small bowel including the duodenum, may be damaged by grasping or cauterizing instruments.
- Spleenic injury
- Minimize this by using open insertion of first cannula and
subsequent cannula insertion under vision .2. Vessel Injuries :
- Mesenteric vessels, iliac vessels, epigastric vessels and
innominate vessels.
3. Injury to Ureter 4. Post operative bleeding
5. Port site metastasis
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Anesthetic Complications :
2. Mask hyper ventilation
Prior Prior to to induction induction 100 100%% oxygen oxygen is is given given by by mask mask ventilation ventilation
Hyperventilation Hyperventilation
D istended stomach D istended stomach
Respiratory D ysfunction Respiratory D ysfunction Liable to injury Liable to injury
during port inser. Or during port inser. Or veress needle inser.veress needle inser.
Management Nasogastric Nasogastric tube tube prior prior to to surgery surgery..
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Anesthetic Complications :3. Air E mbolism
CO 2 used for pneumoperitonium
Gets absorbed into circulation
E mbolus may form and block pulmonary circulation
Loud and clear murmur heard in (R) atrium and (R) ventricle (Mill-Wheel murmur)
Management 1. D irect intracardiac insertion of needle 2. Central venous catheter.
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Management
Continuous I/V assess
E
mergency cart with all resuscitative drugs and defibrillator.
One should be prepared with
Oxygen
Suction
Bag and mask ventilation
Oral and nasal pharyngeal airway, E T tubes of various sizes.
Sphygmomanometer E lectrocardiograph
Pulse oxymeter
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COMPLICATIONS DUE TO PNEUMOPERITONIUM
CO 2 pneumoperitonium
(a) Gas specific effects (b) Pressure Specific E ffects
1. Respiratory Acidosis E xcessive Pressure on IVC 2. Hypercarbia
Reduced VR
Reduced CO
Rapid stretch of peritoneal membrane
Vasovagal response
Bradycardia ,occasionally hypotension
Management
D esufflation of abd.
Vagolytic (Atropine)
Adequate volume replacement
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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
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DVT, Pulmonary Embolism
Increased intraabdominal pressure
Reduced VR (Along with reverse Trendlenburg position)
Venous engorgement
D eep vein thrombosis
Pulmonary E
mbolism Management :
1. Sequential compression stockings
2. Subcutaneous heparin or low molecular weight heparin
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Laparoscopic surgery has documented advantages Lap allows us to do many operations that were once done open
Potentially hazardous in significant cardio respiratory disease
More complex surgery is performed on an aging patient population
with multiple co-morbidities
The Anesthetic technique should therefore reflect the prolonged surgery and medical status of the patient Trade off is visualization and degree of surgeon comfort with
exposure and instrumentation Risk/benefit depends on how safety is enhanced
CONCLUSION
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Ques
t ion
s
T
H A
NK
Y OU
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References 1 ) Desborough JP, Hall G 1993 Endocrine Response to Surgery Anaesthesia Review 10: Churchill Livingstone, London p131
± 2) Hendolin HI, Paakonen ME, Alhava EM, Tervainen R, Kemppinen T, Lahtinen P. Laprascopic or open cholecystectomy: A prospective randomised trial to compare postoperative pain, pulmonaryfunction, and stress response. Eur J Surgery 2000 May; 166(5): 394-9
3) Sharma KC, Brandsetter RD, Brendsilver JM, et al
Cardiopulmonary physiology and pathophysiology as a consequence of laparoscopic surgery. Chest 1996; 110:810-15
4) Kelman GR, Swapp GH, Smith I, et al
Cardiac output and arterial blood gas tension during laparoscopy
± Br J Anaesth 1972; 44:1155-62 5) Hirvonen EA, Nuutinten LS, Kauko M Ventilatory effects, blood gas changes, and oxygen consumption during laparoscopic hysterectomy ± Anesth Analg 1995;80:961-6
6) J.I Alexander
Pain after Laparoscopy British Journal of Anaeasthesia 1997; 79:369-378
7) Barkun J, Barkun AN, Sampalis JS, Freid G, Taylor B Randomoised Controlled trial of Laparoscopic V¶s Mini Cholecystectomy. A National Survey of 4292 hospitals andanalysis of 77 604 cases. 8)The Lancet 1992; 340 : 1116-1119
9) Joris J, Thiry E, Paris P, Weerts J, Lamy M Pain after Laparoscopic Cholecystectomy : Characteristics and Effects of Intraperitoneal Bupivicane. 10) Anaesthesia and Analagesia 1995; 81: 379 ± 384
11) Stiff G, Rhodes M, Kelly A, Telford K, Armstrong CF, Rees BI
Long term pain : Less common after Laparoscopic than Open Cholecystectomy.