6234855 laparoscopic abdominal surgeries

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LAPAROSCOPIC ABDOMINAL SURGERIES



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



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



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



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



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




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




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



ABDOMINAL ACCESS INSTRUMENTS

Open Technique

1. Hasson Cannula

Closed Technique 1. Veress Needle

2. Trocar Sheath

3. assemblies



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



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



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



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



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



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.



LAP HOLES FOR COLON SURGERIES



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



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.



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.



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.




This shows the ́ canulasµ or tubes that are inserted to allow special surgical

instruments to be used inside the abdomen.



Schematic diagram of location of the instrument and camera portals to perform laparoscopic surgery on the colon or rectum.




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



Grasping andDissectingInstruments

Telescopeand Camera

GALL BLADDER LAP SURGERIES/ LAP CHOLECYSTECTOMY

Lap Holes for gall bladder surgeries



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



LAP CHOLESYSTECTOMY

DELIEVERING THE GALL BLADDER



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



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



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



InguinalInguinal

HerniaHernia



APPENDIX LOCATIONS

LAP APPENDICECTOMY



APPENDICITISDISSECTION OF MESOAPPENDIX

LAP APPENDICECTOMY



DIVIDING THE APPENDIX

Stapled

Looped



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



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



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..



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.



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



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



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



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



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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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.

6234855 laparoscopic abdominal surgeries

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