an introduction to minimally invasive surgery i...
TRANSCRIPT
An Introduction to Minimally Invasive Surgery ILaparoscopy - Introduction and basic principles
Philipp Mayhew BVM&S, MRCVS, DACVSAssistant Professor, Small animal surgery
University of California-Davis, USA
Taiwan College of veterinary surgeons - Taiwan 2011
History of Minimally invasivesurgery
Human Medicine:1924 - Heinz Kalk - Germany
- the first to use laparoscopy forliver biopsies
1987 - Philippe Mouret -France
- First videolaparoscopiccholecystectomy
Veterinary Medicine:1985 - Wildt DE et al.
-First report of laparoscopicsterilization in dogs and cats
2000 onwards - increasingliterature
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Progress of MIS
MIS in veterinary medicine haslagged greatly behind humanfieldin the last ten years general
increase in interest hasoccurredDriven by:
-increased availability ofequipment and training-Increased awareness of ownersof MIS procedures
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Current use of MISin veterinarymedicine in the USA
Almost all vet schools and many specialty clinics equipped with MIS equipment
Increase in uptake of MIS in generalpractice is occurring:
-Many attendants at MIS continuing educationmeetings are general practitioners-The more likely general practitioners are toperform MIS the more likely they are to refercases that are complex for MIS
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AdvantagesLess post-operativepain
Faster return tofunction
Smaller incisionsare more cosmetic
Less morbidity (??)
Faster (??)
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Expense of the equipmentExperience necessarySurgical team requiredNeed for conversion? Not all procedures canbe performed vialaparoscopy/thoracoscopy
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Disadvantages
Equipment Medical grade monitor
data recording device
Camera
Xenon light source
Insufflator
TelescopesViewing angles - 0°,
30°
Diameter of scope
-1.9mm, 2.4mm, 2.7mm,3mm,5mm, 10mm
Sheath or no sheath
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Trocars for laparoscopyDisposable
-light weight -more versatile -expense -prevention oftissue trauma
• Non-disposable -cheaper -heavy -reducer capsrequired -Trocars becomeblunt
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InstrumentationHook scissor
right-angle grasping forceps
kelley grasping forceps
Cup biopsy forceps
punch biopsy forceps
Knot pusher
10mm babcock forceps
5mm Babcock forceps
Metzenbaum scissor
Blunt probe
Miscellaneousequipment
specimen retrieval bagsSuction/irrigation
EndoGIA stapling device
Hemostasis -Options
Extracorporeal suture
Intracorporeal suture
Laparoscopic clip applier
Monopolar and bipolar electrocautery
Vessel-sealing technology
- Ligasure (Covidien Inc.)
- Harmonic Scalpel (Ethicon Endosurgery)
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Hemostasis -Extracorporeal ligatures
Multiple types of slipknots
Tied externallyFed through a trocar
with knot pusher
Modified Roeder
4S modified Roeder is most secure (fourwraps and a square knot)
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Shettko DL et al. A comparison of knot security of commonly used hand-tied laparoscopic slipknots. Vet Surg33:521-524, 2004
Extra-corporeal suture placement –modified Roeder knot
Laparoscopic clip applier
Microline Pentax M/L-10 autoclabalemultifire Clip applier
Monopolar and bipolarcautery
Both are possible to use
However monopolar use is more hazardousas injuries to tissues not in field of viewcan be damaged by insulation failure
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Hotblade™ (Patton Surgical Inc.)MonopolarBipolar
Hemostasis - Vessel-sealingdevices
Ligasure© & Enseal©
- bipolar electrocautery- 150-400°F created- melts elastin and collagen- licensed to 7mm a&v
Harmonic Scalpel
- ultrasonic energy
- 50-100°
- licensed to 5mm a&v
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Ligasure - Valleylab
Enseal - Ethicon
Harmonic - Ethicon
Bipolar vessel-sealing device
Laparoscopy - AbdominalAccessHasson technique
- incision made inperitoneum just belowumbilicus
-keep incision very small
-can place sutures aroundtrocar
-use BLUNT cannula
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Hasson technique
Telling whether you’rein? use the insufflator
Most reliable way totell is to see falciformfat
Insert trocar and thenstart to insufflate
-watch insufflator
Should start to seeabdominal tympany fast
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Laparoscopy - Abdominalaccess
Option 2 : Veress needle
-sharp-tipped needle withspring-loaded blunt styletto prevent organpenetration
-Once placed insufflatewith gas and then placefirst cannula
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Veress needle: Midline insertion
3rd option: optical entry
-Laparoscope is placed into trocar as its inserted andlayers of the body wall directly visualized
-rarely used in vet medicine
-Used with increasing frequency in human medicine
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Fios first entry™, Applied medical Inc.
Laparoscopy - Abdominal access
Morbidity associated withaccess
50% of all lap injuries in people are duringaccess
Most common lap access problems in veterinarymedicine
- inability to enter peritoneal cavity or inability totell when cavity is entered/createpneumoperitoneum
- gas insufflation into SQ space
- splenic laceration
- Gastrointestinal penetration
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PneumoperitoneumUsually created with CO2
Can use N20 but NOT with electrocautery
! Supports Combustion
Do not exceed 15mmHg otherwise
-Respiratory and cardiac depression
-decreased perfusion to internal organs
Tilting head up/down compromisesventilation
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Pneumoperitoneum -anesthetic considerations
Must ventilate for patient
Pressure on diaphragm limits TV
C02 is absorbed rapidly and can lead tohypercarbia in animals that are notadequately ventilated
Advise use of capnography/blood gas
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Instrument port placementInsert camera into camera port
Make small skin incision where port to beplaced
Observe with camera entrance of trocar
Use SHARP cannula or threaded trocar
Point away from delicate organs
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Instrument port placement
Tips for MIS-Operating room positioning
Always make astraight line from thecamera operator to thelesion to the monitor
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Tips for MIS -Use gravity to aid in retraction of organs
Lateral tilting, Trendelenburg, ReverseTrendelenburg
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Tips for MIS - Miscellaneous
Empty bladder
One surgeon operates camera and oneinstrumentation
Minimize camera motion – observe lesion
Develop spatial awareness
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ComplicationsHemorrhage - most commonly
splenic laceration
Iatrogenic damage to organs
-Great magnification butdecreased perspective
Seroma formation at port site
Herniation at port site
-Close all port incisions !5mm insize
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Splenic laceration not usually hemodynamically
significant but impairsvisualization
To avoid splenic trauma
-always use blunt trocarspointed away from spleen
-Maintain goodpneumoperitoneum
-manipulate spleen with body ofinstruments
-careful manipulating animalswith trocars in deep positions
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LaparoscopicOvariohysterectomy orOvariectomy
Empty bladder
Place endoscopy tower
at foot of patient
Clip widely
Can use 1,2 or 3-port technique
For all techniques use a routinesubumbilical camera portal
If using one-port technique need to useoperating laparoscope
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Three port techniqueSubumbilical camera portal + two
instrument cannulae (3-5 cm cranial toumbilicus and 3-5 cm cranial to the pubis onmidline)
tilt table 15-30 degrees
The blunt probe is placed in the caudalportal to manipulate organs away fromovaries
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Two port approachUses the transabdominalsuspension suture or KarlStorz suspension deviceOnly caudal most instrumentport is inserted: midwaybetween pubic brim and cameraportal
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Single port approachSingle port laparoscopicovariectomy/ovariohysterectomyhas been described
Operating laparoscope has aworking channel for aninstrument
Single incision multiportdevices are now also available
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operating laparoscope
SILS Port
Pyometra resectionCase selection is important:
- !5-6cm diameter of uterine horns- dogs " 10kg ideal- No evidence of rupture with septic peritonitis
Similar technique is used as for routine OVHUse a wound retraction device to exteriorizethe uterus from the peritoneal cavity
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Laparoscopic liver biopsy
Simplest technique: 5mm cup biopsy forcepsTake several bites from several differentliver lobesCan use Gelfoam to plug biopsy tract ifhemorrhage significant
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Kidney Biopsy
Use 14G spring-fired trucut biopsy needleSmaller dogs and cats can use 16-18Gnever angle towards the renal pelvis
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Rawlings CA, Diamond H, Howerth EW et al. Diagnostic quality of percutaneous kidney biopsy specimensobtained with laparoscopy versus ultrasound guidance in dogs. JAVMA 2003;223:317-321
LaparoscopicPancreatic biopsy
For diagnosis of diffuse pancreatic disease
Avoid body of pancreas
Avoid pancreatic blood supply:
-Right lobe: caudal pancreaticoduodenal A&V
-Left lobe: branches from splenic A&V
Pancreatic biopsy shown to be safe in healthydogs (Harmoinen et al. Vet Therap 2002)
Can use a laparoscopic or lap-assistedtechnique
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Laparoscopic pancreatic biopsy2 instrument port techniqueUse 5mm cup biopsy forceps or endoloopCan use harmonic scalpel or clips also.Harmonic reduces hemorrhage but increasesinflammation (Barnes et al. Vet Surg 2006)
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Laparoscopic-assistedGastrointestinal biopsy
2 instrument ports usuallyplaced10mm babcock forceps used tograsp small intestineStay sutures placed and biopsytaken
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Rawlings et al. Laparoscopic-assisted enterostomy tube placement and full-thickness biopsy of the jejunumwith serosal patching in dogs, AJVR 63, 1313-1316 2002
Lap-assisted GI biopsiesUse of wound retraction device is a variation ofprevious techniqueAlexis™ (Applied medical Inc.) retractor can beused for GI biopsy as well as other organsForms 360° wound protectionradial force produced dilates wound incision
Placement of Alexis woundretractor
Lap-assisted intestinalresection and anastomosis
Laparoscopiccryptorchidectomy
Can be performedlaparoscopic-assisted (1instrument portal) or totallylaparoscopically (2instrument portals)
Great for diagnosis ofcryptorchidism
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Laparoscopic examinationof caudal abdomen
Normal descendedtesticle
Cryptorchid testicle
GubernaculumSpermatic cordTesticular
vessels
Internalinguinal ring
Laparoscopic Cryptorchidism
Testicle removal
Laparoscopic andLaparoscopic-assistedgastropexy
Mortality as high as 15-24% (Brockman et al 1995. Beck et al. 2006)
Lifetime risk in Great Danes: 42% (Glickman et al. 2000)
Other risk factors: High thoracic depth to widthratio, one meal per day, previous splenectomyProphylactic gastropexy
-29.6X decreased mortality (Ward MP et al. 2003)
-at 1yr post-op 100% intact (Rawlings et al. 2002)
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Laparoscopic-assistedgastropexyTo reduce risk for gastric-dilation volvulus
(GDV) syndrome
Camera portal in subumbilical location
Instrumental portal (10mm)
-just lateral to the right margin of the rectusabdominus and 3-5cm caudal to the last rib
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Rawlings CA et al. A rapid and strong laparoscopic-assisted gastropexy in dogs. AJVR 2001
Lap-assisted gastropexyProcedure
Remove all omentumcovering antrum ofstomach
with 10mm babcockforceps grasp a firm holdof the gastric antrum
purge pneumoperitoneum
enlarge the port incisionto approximately 4cm
Exteriorize antrum andplace stay sutures
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Suturing the gastropexy
elevate stomach withstay sutures
An incision is made inthe seromuscularlayer of the stomach
Simple continuoussuture placed fromseromuscular layer ofstomach totransversus abdominis
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Laparoscopic-assistedgastropexy technique
Any Questions?
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