principles of laparoscopic surgery

Principles of Principles of Laparoscopic SurgeryLaparoscopic Surgery

Dr Khalid Javeed KhanDr Khalid Javeed KhanFCPS – FRCSFCPS – FRCS

Associate Professor SurgeryAssociate Professor SurgeryFatima Jinnah Medical CollegeFatima Jinnah Medical College

If you are thinking one year ahead, you plant rice.If you are thinking one year ahead, you plant rice.If you are thinking twenty years ahead, you plant trees.If you are thinking twenty years ahead, you plant trees.

If you are thinking hundred years ahead, If you are thinking hundred years ahead, you educate people.you educate people.

Evolution of Laparoscopic SurgeryEvolution of Laparoscopic Surgery

The use of speculum type intracorporeal viewing devices The use of speculum type intracorporeal viewing devices dates to the Greco-Roman period, when Hippocrates(c.460-dates to the Greco-Roman period, when Hippocrates(c.460-377 BCE) is known to have performed anoscopy for 377 BCE) is known to have performed anoscopy for diagnosis of fistula and hemorrhoids.diagnosis of fistula and hemorrhoids.

In 1805 Phillip Bozzini developed the Lichtleiter (light In 1805 Phillip Bozzini developed the Lichtleiter (light conductor). This instrument employed a candle, mirrors and conductor). This instrument employed a candle, mirrors and various specula for viewing insidevarious specula for viewing inside

The next major advance came in 1853 when Antonio The next major advance came in 1853 when Antonio Desormeaux developed his versatile endoscope that Desormeaux developed his versatile endoscope that burned gazogene(alcohol and turpentine) as a light sourceburned gazogene(alcohol and turpentine) as a light source

Evolution of Laparoscopic SurgeryEvolution of Laparoscopic Surgery

Laparoscopy is a combination of two Greek words, Laparo, Laparoscopy is a combination of two Greek words, Laparo, the flank and skopein, to examinethe flank and skopein, to examine

First performed in 1901 by George Kelling of Germany First performed in 1901 by George Kelling of Germany when he entered the abdominal cavity of a dog after air when he entered the abdominal cavity of a dog after air insufflationinsufflation

Eight years later Hans Christians(sweden) reported first Eight years later Hans Christians(sweden) reported first laparoscopy and thoracoscopy in humanslaparoscopy and thoracoscopy in humans

In United states Bertram bernheim was the first to perform In United states Bertram bernheim was the first to perform

laparoscopy in 1911laparoscopy in 1911

The first atlas and textbook of laparoscopic surgery was The first atlas and textbook of laparoscopic surgery was written in Germany by Roger Korbsch In 1927written in Germany by Roger Korbsch In 1927

The technology developmentThe technology development

Heinz kalk of Germany (hepatologist) in 1927 introduced Heinz kalk of Germany (hepatologist) in 1927 introduced forward viewing scope which improved operator orientationforward viewing scope which improved operator orientation

The use of COThe use of CO2 2 to create pneumoperitoneum was first to create pneumoperitoneum was first recommended in 1924 by Richard Zollikofer(swiss)recommended in 1924 by Richard Zollikofer(swiss)

The preferred route of insufflation was the Veress needle The preferred route of insufflation was the Veress needle introduced by Janos Veress of Hungary In 1938introduced by Janos Veress of Hungary In 1938


Since 1930 laparoscopic tubal ligation have been performed Since 1930 laparoscopic tubal ligation have been performed by the gynecologistsby the gynecologists

The 1960s and 1970s brought two major developments, the The 1960s and 1970s brought two major developments, the first was the introduction of the rod lens system in 1960 by first was the introduction of the rod lens system in 1960 by Harold Hopkins of England, the second in 1963 was cold Harold Hopkins of England, the second in 1963 was cold light transmission via fiber optic cables developed by light transmission via fiber optic cables developed by gastroenterologist Hirschowtz in Ann arbor, Michigan.gastroenterologist Hirschowtz in Ann arbor, Michigan.

The combination of these two technologies positioned The combination of these two technologies positioned laparoscopy as a viable therapeutic modality for a variety of laparoscopy as a viable therapeutic modality for a variety of problemsproblems


The automatic insufflator was designed by gynecologist and The automatic insufflator was designed by gynecologist and engineer Karl semm in 1966 and greatly reduced the engineer Karl semm in 1966 and greatly reduced the adverse effects of pneumoperitoneumadverse effects of pneumoperitoneum

The technique of direct visualization of the peritoneal cavity The technique of direct visualization of the peritoneal cavity was introduced by Hasson in 1974 was introduced by Hasson in 1974

Laparoscopic surgeryLaparoscopic surgery

First laparoscopic cholecystectomy was performed in 1988 First laparoscopic cholecystectomy was performed in 1988 by Mouret of Franceby Mouret of France

No surgical procedure is without risk. Despite the minimally No surgical procedure is without risk. Despite the minimally invasive nature of laparoscopic surgery, the potential for invasive nature of laparoscopic surgery, the potential for adverse outcome is present and should be taken as adverse outcome is present and should be taken as seriously as in a traditional open procedure.seriously as in a traditional open procedure.

Patient selection and preparation for a laparoscopic Patient selection and preparation for a laparoscopic procedure is the first step in ensuring successful outcomeprocedure is the first step in ensuring successful outcome

Preoperative evaluationPreoperative evaluation

A careful history and physical examination are the A careful history and physical examination are the cornerstones of patient selection for surgery. Preexisting cornerstones of patient selection for surgery. Preexisting that predispose patient to both anesthetic and surgical that predispose patient to both anesthetic and surgical complications must be identified.complications must be identified.

Signs and symptoms suggestive of cardiac or pulmonary Signs and symptoms suggestive of cardiac or pulmonary disease should be specifically sought.disease should be specifically sought.

Preoperative laboratory evaluation depends on the nature Preoperative laboratory evaluation depends on the nature of surgery, the patients past medical history, and the of surgery, the patients past medical history, and the preferences of both the surgeon and the anesthetist.preferences of both the surgeon and the anesthetist.

In general this may include B/C, S/E, urinalysis. Coagulation In general this may include B/C, S/E, urinalysis. Coagulation studies if required, and EKG and chest X-ray for patients studies if required, and EKG and chest X-ray for patients above 40above 40


It is important to carefully evaluate the patient with known It is important to carefully evaluate the patient with known or suspected pulmonary disease prior to undertaking a or suspected pulmonary disease prior to undertaking a laparoscopic procedure, as pneumoperitoneum and laparoscopic procedure, as pneumoperitoneum and hypercarbia may be poorly toleratedhypercarbia may be poorly tolerated

Pulmonary function tests and arterial blood gases Pulmonary function tests and arterial blood gases determination may be helpful in deciding determination may be helpful in deciding

It is important to determine the baseline pCO2 in patients It is important to determine the baseline pCO2 in patients with known pulmonary disease so that the extent of with known pulmonary disease so that the extent of hyperventilation can be better evaluated intra operativelyhyperventilation can be better evaluated intra operatively

The cardiac risk factors need to be carefully evaluatedThe cardiac risk factors need to be carefully evaluated


The past surgical history and the location of prior incisions The past surgical history and the location of prior incisions should be specifically considered as this will aid in the should be specifically considered as this will aid in the planning of access method and trocar placementplanning of access method and trocar placement

The patient should be specifically examined for an umbilical The patient should be specifically examined for an umbilical hernia or urachal cyst hernia or urachal cyst

The ability to abduct hips and arms should be assessed The ability to abduct hips and arms should be assessed

The presence of ascites will effect abdominal access and The presence of ascites will effect abdominal access and may complicate the postoperative course if the fluid may complicate the postoperative course if the fluid becomes infected or leaks from the trocar sitebecomes infected or leaks from the trocar site


Patients with history of DVT should be carefully evaluated Patients with history of DVT should be carefully evaluated preoperatively, as many procedures are lengthy, require preoperatively, as many procedures are lengthy, require the reverse Trendelenberg position, and can have the reverse Trendelenberg position, and can have significant inferior vena cave compression secondary to the significant inferior vena cave compression secondary to the pneumoperitoneum.pneumoperitoneum.

All patients should have compression stockings in place All patients should have compression stockings in place before the induction of general anesthesia, those at high before the induction of general anesthesia, those at high risk may need additional measures including pneumatic risk may need additional measures including pneumatic compression devices compression devices

Contraindications to Laparoscopic surgeryContraindications to Laparoscopic surgery

Hypovolemic shock as the patient is less prepared to Hypovolemic shock as the patient is less prepared to tolerate the further decrease in venous return. In addition tolerate the further decrease in venous return. In addition these patients will benefit from the most expeditious these patients will benefit from the most expeditious operation, as their end organ perfusion will only be further operation, as their end organ perfusion will only be further challenged by longer anesthesiachallenged by longer anesthesia

A laparoscopic procedure is contraindicated in patients with A laparoscopic procedure is contraindicated in patients with significant ongoing abdominal bleeding due to both significant ongoing abdominal bleeding due to both hypovolemia and technical issueshypovolemia and technical issues

Contraindications to Laparoscopic surgeryContraindications to Laparoscopic surgery

Hemodynamic instability for any reason, poor candidates Hemodynamic instability for any reason, poor candidates for laparoscopy. The effects of pneumoperitoneum as well for laparoscopy. The effects of pneumoperitoneum as well as the extremes in patient positions during laparoscopy will as the extremes in patient positions during laparoscopy will be poorly tolerated by patients already compromisedbe poorly tolerated by patients already compromised

Massive abdominal distension- in patients with extremely Massive abdominal distension- in patients with extremely dilated intestines it is unsafe to attempt to establish dilated intestines it is unsafe to attempt to establish pneumoperitoneum due to likelihood of bowel puncturepneumoperitoneum due to likelihood of bowel puncture

Inability to tolerate a laparotomyInability to tolerate a laparotomy

Surgeon inexperienceSurgeon inexperience

Relative Contraindications to Laparoscopic surgeryRelative Contraindications to Laparoscopic surgery

General peritonitis of uncertain origin, patients with diffuse General peritonitis of uncertain origin, patients with diffuse peritonitis, especially when the etiology is unclear, are not peritonitis, especially when the etiology is unclear, are not ideal candidates for a laparoscopic explorationideal candidates for a laparoscopic exploration

Advanced cardiopulmonary disease, the cardiopulmonary Advanced cardiopulmonary disease, the cardiopulmonary effects of pneumoperitoneum and the duration of the effects of pneumoperitoneum and the duration of the procedure may make an open approach more suitable for procedure may make an open approach more suitable for these patientsthese patients

Advanced pregnancy, particularly in the lower abdomen are Advanced pregnancy, particularly in the lower abdomen are difficult in near term patientsdifficult in near term patients

Uncorrectable coagulopathyUncorrectable coagulopathy

Portal hypertensionPortal hypertension

Laparoscopic suiteLaparoscopic suite

A dedicated laparoscopic suite in the operating room is A dedicated laparoscopic suite in the operating room is becoming increasingly popularbecoming increasingly popular

Each suite carries the essential basic equipment for Each suite carries the essential basic equipment for laparoscopic surgery, whether they are built in to the actual laparoscopic surgery, whether they are built in to the actual room suspended from the ceiling or are mounted on the room suspended from the ceiling or are mounted on the mobile carts video towers)mobile carts video towers)

Appropriate room setup and patient positioning are also Appropriate room setup and patient positioning are also extremely important extremely important

The entire operating team of nurses, technicians, surgeons The entire operating team of nurses, technicians, surgeons and anesthetists must be familiar with the demands of and anesthetists must be familiar with the demands of laparoscopic patient, with the operating room and laparoscopic patient, with the operating room and equipment equipment

Basic laparoscopic equipmentBasic laparoscopic equipment

The insufflation systemThe insufflation system

Imaging systemImaging system

Irrigation/aspiration unitIrrigation/aspiration unit

Electrocautery unitElectrocautery unit

Insufflation systemInsufflation system

The insufflation system allows the surgeon to create a The insufflation system allows the surgeon to create a working space in the abdomen in which to see and operateworking space in the abdomen in which to see and operate

Pneumoperitoneum is maintained throughout the Pneumoperitoneum is maintained throughout the procedure and it should be directly controlled by the procedure and it should be directly controlled by the surgeon or the circulating nursesurgeon or the circulating nurse

The insufflation system should be continuously in direct The insufflation system should be continuously in direct view so the surgeon can monitor its minute-to-minute view so the surgeon can monitor its minute-to-minute functionfunction


The major components of an insufflation system are the The major components of an insufflation system are the insufflant, the insufflator, and the insufflation needle or insufflant, the insufflator, and the insufflation needle or trocartrocar

For laparoscopic procedures the insufflant medium is gas. For laparoscopic procedures the insufflant medium is gas. Various gases have been evaluated including, air, oxygen, Various gases have been evaluated including, air, oxygen, carbon dioxide, nitrous oxide and inert gases such as carbon dioxide, nitrous oxide and inert gases such as xenon, argon and krypton.xenon, argon and krypton.

Air and inert gases are insoluble in blood and therefore Air and inert gases are insoluble in blood and therefore carry a risk of air embolism.carry a risk of air embolism.

Oxygen is flammable and so not usedOxygen is flammable and so not used

COCO22 is not flammable and rapidly dissolves in blood is not flammable and rapidly dissolves in blood


The insufflator is a device that allows the flow of gas from a The insufflator is a device that allows the flow of gas from a cylinder into the space being insufflated.cylinder into the space being insufflated.

It adjusts the rate of flowIt adjusts the rate of flow

It maintains a required intraperitoneal pressureIt maintains a required intraperitoneal pressure

It displays the total amount of gas insufflatedIt displays the total amount of gas insufflated

It also indicates the pressure in the cylinderIt also indicates the pressure in the cylinder


Most units offer flow rate 1-5 L/min(low), 6-10 Most units offer flow rate 1-5 L/min(low), 6-10 L/min(medium) 11-15 L/min(high)L/min(medium) 11-15 L/min(high)

Pressure should be maintained between 10 and 15mmHg Pressure should be maintained between 10 and 15mmHg during laparoscopic proceduresduring laparoscopic procedures

At high pressure >25mmHg the risk of gas absorption and At high pressure >25mmHg the risk of gas absorption and air embolism is greatly increasedair embolism is greatly increased

There is increased risk of decreased venous return resulting There is increased risk of decreased venous return resulting from compression of the IVC and impaired ventilation from compression of the IVC and impaired ventilation secondary to pressure on the diaphragm secondary to pressure on the diaphragm


The quality of the imaging system is extremely important The quality of the imaging system is extremely important as it functions as the eye of the operating team. as it functions as the eye of the operating team. Components include the laparoscope, camera, monitor and Components include the laparoscope, camera, monitor and light sourcelight source

The laparoscope allows light transmission into the The laparoscope allows light transmission into the peritoneal cavity to the surgical field and image peritoneal cavity to the surgical field and image transmission out of the peritoneal cavity to the camera.transmission out of the peritoneal cavity to the camera.

Most laparoscopes consist of a rigid rod lens imaging Most laparoscopes consist of a rigid rod lens imaging system, an eyepiece and a flexible fiber optic light system, an eyepiece and a flexible fiber optic light conducting cable.conducting cable.


Common sizes are 10 and 5mmCommon sizes are 10 and 5mm

Larger sizes are capable of transmitting greater amounts of Larger sizes are capable of transmitting greater amounts of light, a wider field of vision and better image resolutionlight, a wider field of vision and better image resolution

Both sizes are available with either straight or angled Both sizes are available with either straight or angled lenses, 30-degree, 45-degree and 50-degreelenses, 30-degree, 45-degree and 50-degree

The camera magnifies the endoscopic view by 15-fold The camera magnifies the endoscopic view by 15-fold allowing high resolution imaging of anatomical detailsallowing high resolution imaging of anatomical details


The camera attaches to the eyepiece of the laparoscope The camera attaches to the eyepiece of the laparoscope and transmits digitized optical information from the scope and transmits digitized optical information from the scope via cable to the video box, the digital image data are then via cable to the video box, the digital image data are then reconstructed and displayed on the monitorreconstructed and displayed on the monitor

The camera should be focused , and the camera/video The camera should be focused , and the camera/video system should be white balanced to optimize image color system should be white balanced to optimize image color representationrepresentation

Insertion of a room temperature laparoscope into the Insertion of a room temperature laparoscope into the peritoneal cavity will result in fogging of the lensperitoneal cavity will result in fogging of the lens

Irrigation/aspiration systemIrrigation/aspiration system

In any laparoscopic procedure a surgeon will benefit by In any laparoscopic procedure a surgeon will benefit by using this device to keep the field cleanusing this device to keep the field clean

The irrigation fluid can flow by gravity, but the use of a The irrigation fluid can flow by gravity, but the use of a pressurized bag provides more active flowpressurized bag provides more active flow

The most common irrigants are normal saline with 5000 The most common irrigants are normal saline with 5000 units heparin added per liter or lactated ringer solutionunits heparin added per liter or lactated ringer solution

Electrocautery Electrocautery

Tissue cutting and coagulation is best achieved with Tissue cutting and coagulation is best achieved with electrocautery unit, controlled by foot pedal by the surgeonelectrocautery unit, controlled by foot pedal by the surgeon

The most commonly used tip configurations are spatula, The most commonly used tip configurations are spatula, dissectors, and right angled L hook, others include scissors, dissectors, and right angled L hook, others include scissors, dissectors and graspersdissectors and graspers

All the above are insulated with a thin nonconductive All the above are insulated with a thin nonconductive coatingcoating

Laparoscopic proceduresLaparoscopic procedures

Gastrointestinal tract, Gastrointestinal tract, • Laparoscopic assisted esophagectomyLaparoscopic assisted esophagectomy• Laparoscopic cardiomyotomy for achalasiaLaparoscopic cardiomyotomy for achalasia• Fundoplication for GORDFundoplication for GORD• Bariatric surgeryBariatric surgery• Gastrectomy and small bowel surgeryGastrectomy and small bowel surgery• AppendectomyAppendectomy• Colon surgeryColon surgery• Adhenolysis and diagnostic surgeryAdhenolysis and diagnostic surgery


Hepatobiliary systemHepatobiliary system• CholecystectomyCholecystectomy• Liver and bile duct proceduresLiver and bile duct procedures• Pseudocyst and pancreatic abscessPseudocyst and pancreatic abscess• Laparoscopic bypass proceduresLaparoscopic bypass procedures• SplenectomySplenectomy


Endocrine surgeryEndocrine surgery• AdrenalectomyAdrenalectomy• Enucleation of benign pancreatic islet tumorsEnucleation of benign pancreatic islet tumors• Whipple’s procedureWhipple’s procedure• Endoscopic neck surgeryEndoscopic neck surgery


Inguinal herniasInguinal hernias Ventral herniasVentral hernias NephrectomyNephrectomy Ureter and bladderUreter and bladder HysterectomyHysterectomy MyomectomyMyomectomy Tubal ligation/ectopic pregnancyTubal ligation/ectopic pregnancy

The endThe end