laproscopy in general surgery

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Diagnostic &Therapeutic Laparoscopy

by

prof/ gouda ellabban

HISTORICAL PERSPECTIVE Abulkasim of Cordoba(980-

1037) ..illuminate deeper body cavities by reflection of nature light

Hippocrates also detailed the use Of speculum, or primitive anoscope, for examining hemorrhoids.

Bozzini(1805)…. First cystoscope. physicians began using candles or paraffin lamps for illumination.yyryyy

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HISTORICAL PERSPECTIVE The first experimental laparoscopy was

performed in Berlin in 1901 by the German surgeon Georg Kelling, who used a cystoscope to peer into the abdomen of a dog after first insuffiating it with air The first human laparoscopy was performed in Sweden by Jacobeus in 1910 to investigate ascites. In 1929, Kalk advocated a second puncture site for the establishment of pneumoperitoneum

HISTORICAL PERSPECTIVEFiberoptic technology and closed-circuit

videolaparoscopy evolved in the 1950s. Kurt Semm in particular became a powerful

advocate of laparoscopy including an automatic air insufflation

device,electrocoagulator, and aspiration/irrigation system and is credited with performing the first laparoscopic appendectomy in 1983.

LAPAROSCOPYDIAGNOSTIC

THERAPEUTIC

What is a diagnostic laparoscopy?

DEFINITION :A diagnostic laparoscopy is a technique used by surgeons to obtain information about the inside of the abdomen without making a large incision.

Translated from the Greek, "Laparoscopy" means examination of the abdomen with a scope, which is also known as an Endoscope. The other terms used are "key-hole surgery" and " Minimally Invasive Surgery"

What are the informations

your patient should know ????

SURGICAL TECHNIQUE OF LAPAROSCOPY

1.The establishment of pneumoperitoneum:

a)A Veress needle b) trendelenburg's position to displace the bowel from the pelvis. C)needle is inserted pointing inferiorly d)insufflation Of C02 is begun until an intraperitoneal pressure of 12 to 14 mmHg is attained.

2. The peritoneal cavity is inspected to identify any injury caused by

the initial insertions. Then the remaining trocars are placed under direct laparoscopic observation, minimizing the possibility of visceral injury. The different instruments needed to undertake the procedure may then be inserted through the trocars. The sites, sizes, and number of trocars placed may vary with the procedure

Gas flow/min

Intra peritonealpressure

On/off

Memory

Total gas/Or

Start insufflation

Maximum pressure

Starting flowRate/min

Verus needle

Aspiration/saline injection

Drop test

10 mm

5 mm

See wall blood

vessels

Trocar entery undervision

SURGICAL TECHNIQUE OF LAPAROSCOPY

Routine laparoscopic examination of the abdomen may include evaluation of peritoneal surfaces, diaphragm, liver, spleen, gallbladder, stomach, small intestine, colon, pelvic organs, and retroperitoneal tissues and organs. Appropriate biopsies, cytology, intraoperative ultrasound, cultures and fluid analysis may be performed as necessary and / or other imaging modalities may be useful

The right lobe of the normal liver shows a smooth liver surface with reddish brown color. The consistency of the liver surface is elastic soft and a liver edge sharpened. In this picture, a normal gall bladder is also seen.

The left lobe of the normal liver has the same features as The upper

pole of the normal-sized spleen is seen in the right upper corner.

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DIAGNOSTIC LAPAROSCOPY

Acute Abdomen“ Equivocal physical sings, especially in women of child bearing age “Acute appendicitisIntestinal obstructionPIDRuptured ovarian cystEctopic pregnancy

common symptoms that require a diagnostic laparoscopy

Abdominal pain: Abdominal pain can be acute or chronic .The cause of both kinds of pain: appendicitis, acute cholecystitis, adhesions, pelvic infections, endometriosis, abdominal bleeding and less common, cancer, when clinical examination and standard tests have not yielded a diagnosis. The diagnostic accuracy of laparoscopy in the evaluation of acute abdominal pain has been reported to be 80–90 %

The surgeon can identify the problem and even correct it during the same procedure.

Diagnostic Laparoscopy for acute abdomen

Critically iIl Patients. The evaluation of an acute abdomen in individuals in intensive care units is often challenging. It is possible to perform diagnostic laparoscopy at the bedside with local anesthesia and sedation. In a study of 25 intensive care unit patients with a suspected abdominal pathologic condition, the accuracy of laparoscopy was 96 percent in determining the need for laparotomy.

Uterus

Douglas pouch

Peritoneal fluid

Inflammed appendixcoecum

Mesoappendix

Base of appendix ligated

Free pus from base of appendixdue to perforation

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DIAGNOSTIC LAPAROSCOPYAbdominal Trauma

INDICATIONS Equivocal physical singsStable patientComatose patients Fracture pelvis with retroperitoneal heamatomaFINDINGSHemoperitoneumVisceral injuryRetro peritoneal hematoma

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DIAGNOSTIC LAPAROSCOPY

Chronic Abdominal ConditionsAbdominal pain for investigation Abdominal TB; Tubercles, Ascites, Adhesions, Mesenteric lymphadenopathy Crohns diseaseAbdominal MassesLiver massMesenteric lymphadenopathyOvarian tumor,Cysts

Diagnostic Laparoscopy for Small bowel

Definitive diagnosis of Crohn's disease, T.B, Tumors, Intestinal obstruction

TB of the abdomen is a difficult condition to diagnose. The treatment is based on suspicion rather than any objective criteria. In such situations, laparoscopy can provide the answer.

Diagnostic Laparoscopy for Small bowel

Lysis of adhesions: In those patients with moderate adhesion where a simple lysis can be performed using local anesthesia on the adjacent structures, a successful adhesiolysis can eliminate a general anesthetic procedure for five times the cost and recovery time.

Adhesion

RT. Liver lobe

Release of adhesion

Adhesion forceps

Ant. Abdominal wall

Peritoneal wall

Omentaladhesion

Viral liver cirrhosis Macronodular cirrhosis

with narrow stroma is characteristic in viral liver cirrhosis. Liver edges are extremely dull and the liver surface is coarsely nodular

DIAGNOSTIC LAPAROSCOPY

Staging Of Malignancy

Liver metastasisPeritoneal metastasisAscitesLymphadenopathy

Liver Biopsy

While percutaneous biopsy of a liver mass is now

performed under CT or ultrasound guidance, 1)laparoscopy may detect additional smaller lesions. 2) uncorrectable coagulation defect and a critical need for tissue diagnosis, biopsy under direct laparoscopic vision provides an opportunity to control bleeding . 3) Hepatic cirrhosis, chronic hepatitis, and fatty infiltration, direct visualiztion is extremely useful in assessing the pattern and severity of disease .

A review of blind percutaneous biopsy vers laparoscopically directed biopsy for the diagnosis of cirrhosis in over 6000 patients revealed a false-negative rate of 24 % for blind biopsy, compared with only 9 % for laproscopy.

Hepatocellular carcinoma

more than 90% of HCC cases are acompanied with background liver lesions including liver cirrhosis or chronic hepatitis. Thus, non-tumorous portions of the liver also show the changes corresponding to those.

Metastatic liver tumor

Protruded tumor formation with a slight depression in the center is characteristic in metastatic liver tumor. The depressed center showes whitish color. This finding is called "cancer nabel"

Diagnostic Laparoscopy in Children

Laparoscopy can be a diagnostic procedure in children (e.g., to evaluate the undescended testis as part of the evaluation of intersex, in the diagnosis of the acute abdomen, and in staging pediatric cancer).

Once the diagnosis is made,laparoscopic techniques can help to treat the condition (unwinding adnexal torsion, appendectomy, adhesiolysis,resection of Meckel's diverticulum, or even removal of a pheochromocytoma).

Laparoscopy in Children

With the laparoscope, even large, solid intra-abdominal masses such as the kidney or spleen can be removed. As experience has increased, a variety of more sophisticated procedures are now possible (e.g.,colectomy, "pull-through" for Hirschsprung's disease,pyeloplasty, and treatments for vesicoureteral reflux, gut malrotation, and choledochal cysts).

Contraindication

Absolute inability to anesthetize Relative Training of surgeon Carcinomatosis Previous surgery Fitness for pneumoperitoneum Obesity Portal hypertension Coagulopathy

CONTRINDICATIONS

Contraindications may include 1.hemodynamic instability 2.uncorrected coagulopathy. 3.generalized peritonitis. 4.severe cardiopulmonary disease. 5.abdominal wall infection. 6.multiple previous abdominal procedures 7.late pregnancy.

However, the final decision is determined not only by the clinical conditions, but also by the surgeon's judgement.

Where should be done?Whom should do it?

Diagnostic laparoscopy is safe and well tolerated and can be performed in an outpatient or inpatient setting under general anesthesia.

Diagnostic laparoscopy should be performed by physicians trained in laparoscopic techniques and who are able to recognize and treat common complications. The physician should also be able to perform additional therapeutic procedures when indicated.

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THERAPEUTIC LAPAROSCOPY

Common ProceduresCholecystectomyAppendectomyHernioplastyRepair of perforated DUAdhesolysis

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THERAPEUTIC LAPAROSCOPY

Advanced GS ProceduresSplenectomyColectomyVagotomyNissen fundoplicationAdrenalectomyBanding for obesity

THERAPEUTIC LAPAROSCOPY

Other Procedures

NephrectomyOopherectomyHystrectomy

What are the benefits?

.Two or three tiny scars instead of one large abdominal scar• Shorter hospital stay – you may leave the hospital on the same day• Reduced postoperative pain• Shorter recovery time and quicker return to daily activities, including work

Perceived benefits

1.Less cardiorespiratory complications2.Reduced risk of DVT/PE3.Reduced incisional hernia rate4.Fewer adhesions and less likely to develop obstruction5.Better visualisation for the surgeon6.Less ileus from reduced handling7.Improved cosmesis8.Reduced contamination of theatre staff (Hepatitis and HIV)Reduced outpatient/social costs

COMPLICATIONSGeneral

Complications may be associated with: The anaesthetic The induction of pneumoperitoneum Insertion of primary and secondary trocars Thermal Instruments Mechanical Instruments Other associated conditions

COMPLICATIONSGeneral

Complications may be associated with: The anaesthetic The induction of pneumoperitoneum Insertion of primary and secondary trocars Thermal Instruments Mechanical Instruments Other associated conditions

Complications from Needle and Trocar Insertion

Veress needle insertion and trocar insertion may cause injury to the intestines, stomach, bladder.The rate is higher, as this is done blindly. The overall incidence of visceral injury in several large series ranges from 0.05 to 0.2 percent .

Vascular Injury: The most life-threatening laparoscopic complications . A survey of 77,604 laparoscopic cholecystectomies identified 36 (0.05 percent) injuries to the aorta, inferior vena cava, or iliac vessels. The mortality in these patients was 8.8 percent. In a collected series of 16 major vascular injuries, mortality was 13 percent .

Complications Gastrointestinal Injury: Clinically significant

stomach or intestinal injury from needle or trocar insertion has been reported in approximately 0.01 to 0.4 percent of patients. Undetected bowel injury is a major contributor to postoperative mortality. Such patients present with sepsis or peritonitis. Intraabdominal abscess or fistulas may occur at a later date. In a survey of over 75,000 laparoscopic cholecystectomies, 4.6 percent of patients with gastrointestinal injuries died

Wound Complications General

Hernia.( 0.1 to 0.3 %) The larger the diameter of the cannula used, the more likely the possibility of herniation. Wound infection is a predisposing factor. It is generally recommended that fascial defects from cannulas 10 mm or larger be sutured.

Wound Infection. This is an unusual occurrence and depends on the operation performed. Procedures such as diagnostic laparoscopy have extremely low rates (0.1%). Wound infection rates after laparoscopic cholecystectomy may be as high as 1 %. The use of a bag or to remove the specimen may decrease the incidence of infection.

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LAPAROSCOPYCOMPLICATIONS OF LAP CHOLE

CBD injury : Nightmare for surgeon Should be mentioned as first specific complicationTypes : 1. Intra operatively 2. post op. : Obstructive jaundice, biliary peritonitis Diagnosis & management of each one is very importantCystic duct leakMissed stones abscessLiver injury

Future

Advanced equipment3d videoBetter trainingRobotic surgeryVirtual reality

LAPAROSCOPY

THANK YOU