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AN INTRODUCTION TO LAPAROSCOPIC SURGERY

AN INTRODUCTION TO LAPAROSCOPIC SURGERY. By; Col.Abrar Hussain Zaidi. PROLOGUE. THE ORIGIN. Innate Human Desire – to Be Minimally Harmed / Surgically. This thought makes the foundation of what is now referred to as minimally invasive surgery. Nomenclature.

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AN INTRODUCTION TO LAPAROSCOPIC SURGERY

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  1. AN INTRODUCTION TO LAPAROSCOPIC SURGERY By; Col.Abrar Hussain Zaidi

  2. PROLOGUE

  3. THE ORIGIN Innate Human Desire – to Be Minimally Harmed / Surgically

  4. This thought makes the foundation of what is now referred to asminimally invasive surgery.

  5. Nomenclature Minimally invasive surgery (MIS), bandaid surgery, keyhole surgery, or pinhole surgery is a modern surgical technique in which: operations are performed through small incisions (usually 0.5-1.5cm) as compared to larger incisions needed in traditional surgical procedures

  6. Nomenclature Scopic surgery Endoscopic surgery. broader term For the use of an endoscope Laparoscopic /Thoracoscopic/others

  7. Nomenclature • Laparoscopic surgery Laparoscopic surgery includes operations within the abdominal or pelvic cavities • Thoracoscopic surgery.[VATS] MIS surgery performed on the thoracic or chest cavity

  8. Other Endoscopic /Scopic surgery • Arthroscopy • Cranioscopy • Endoluminal

  9. HISTORY A physician’s desire to evaluate the inside of a patient's body with limited injury existed as far back asHippocrates (460-375 B.C.). He made reference to examination of the rectum with a speculum.

  10. Phillip Bozzini (1773-1809) The light conductor invention • In 1901 George Kellingexamine the abdominal cavity of dogs • Jacobeus [1901--?] a surgeon from Stockholm, coined the phrases "laparoscopie" and "thoracoscopie". first to publish a series of abdominal and thoracic examination in humans using minimally invasive techniques.

  11. Bertram Berheim from Johns Hopkins in 1911 to perform the first laparoscopy in the United States. • The advent of the insufflator (Kurt Semm), fiberoptics and the rod-lens system (Harold Hopkins)-1958.

  12. First solid state camera in 1982 • 1987 -Phillipe Mouret performed the first laparoscopic cholecystectomy. An ignition for the laparoscopic surgery.

  13. During the past <two decades, a dynamic evolution in Minimally Invasive Surgery has occurred that has no equal in the history of surgery

  14. SPECTRUM The world of MIS has expanded during the last decade to include most surgical fields; • Abdomen and thorax • Brain and heart, • Gynaecology • Orthopaedics

  15. SPECTRUM DIAGNOSTIC THERAPEUTIC

  16. Operative Cholecystectomy Appendicectomy Bowel resection Repair of Prolapse Nephrectomy Bypass Spleenectomy Gynaecological SPECTRUM Diagnostic • TB/Crohn’s • Diverticulitis • Lymphadenopathy • Benign renal disease • Gastric Obstruction • Some Splenic disorders

  17. GROWING SPECTRUM TELEROBOTICS • 1994 --- the introduction of roboticsinto the operating room. • A robotic arm was used to hold the camera replacing the camera operator. • 1996- a surgery was performed with the patient and surgeon in different locations using the Internet - Telesurgery

  18. Future Technologies yet to be introduced - seem boundless. The operating room of tomorrow may not be the same as it is today. Your presence right there may not be necessary [ thanks to telerobotics]

  19. Conceptual debates - ISSUES • Post-operative pain • Recovery / Hospital stay • Visual field for surgeons • Operation time • Cost • Cosmetic outcome • Patient acceptance • The complications

  20. Advantages/ benefits Reduced post operative pain and analgesic requirement Reduced operative trauma Reduced bleeding Faster recovery, discharge and return to work Reduced wound infection, seroma and haematoma Reduced chronic wound pain Less cardiorespiratory complications

  21. Advantages/ benefits • Less ileus from reduced handling • Improved cosmesis • Reduced contamination of theatre staff (Hepatitis and HIV) • Interesting for surgeons • Reduced outpatient/social costs

  22. Advantages/ benefits • Reduced risk of DVT/PE • Reduced incisional hernia rate • Fewer adhesions and less likely to develop obstruction • Immunological benefits • Better visualisation for the surgeon

  23. Disadvantages/ Risks • High risk of co-lateral injury eg Common bile duct in lap cholecystectomy • Bowel/bladder/vascular injury in hernia surgery • Verres needle injury • Diathermy may lead to organ damage eg late cbd stricture • Increased operating time

  24. Disadvantages/ Risks • Increased costs due to theatre time and equipment • Tumour seeding • Poor quality surgery eg cancer resection • Loss of tactile sensation • Long learning curve • Loss of training opportunity eg appendicitis and inguinal hernia • Some surgeons not able to develop skills

  25. THE ART AND THE CRAFT

  26. THE EQUIPMENT • THE TECHNIQUE • THE TRAINING

  27. THE EQUIPMENT

  28. The Equipment • Laparoscope/video system • Light source • Insufflator • Diathermy /coagulation:cutting system [+Harmonic ace] • Suction irrigation system • Specialized hand instruments

  29. Trolley

  30. The Equipment • Laparoscope/video system There are two types: • Telescopic rod lens system, that is connected to a video camera (single chip or three chip) or • A digital laparoscope where the charge-coupled device[CCD] is placed at the end of the laparoscope, eliminateing the rod lens system.

  31. Telescopic rod lens system There are three important structural differences in telescope available in the market. • 6 to18 rod lens system telescopes • 0 to 120 degree telescopes • 1.5 mm to 15 mm of telescopes

  32. Telescopic rod lens system

  33. Video camera Single chip VS three chip Three primary colours (Red,Blue, Green). In single chip camera all these 3 primary colours are sensed by single chip. In three chip camera there are 3 CCD- Chips for separate capture and processing of 3 primary colours—High resolution

  34. Video camera

  35. Monitor • No different from the T.V. • Basic principle of image reproduction is horizontal beam scanning on the face of the picture tube.

  36. The existing television systems in use differ according to the country. • The U.S.A uses the NTSC (National Television System Committee) system. • In European countries the PAL (Phase Alternation by Line) system is in use. • French system called SECAM (Sequential color and memory).

  37. Light source A fiber optic cable system connected to a 'cold' light source (halogen or xenon), to illuminate the operative field,

  38. Light source

  39. Fiber optic cable

  40. Insufflator The abdomen is insufflated with carbon dioxide gas [pneumoperitomeum] to create a working and viewing space. Elevates the abdominal wall above the internal organs like a dome. Gasless surgery –with mechanical wall elevators

  41. Coagulation & cutting System Diathermy monopolar / bipolarHarmonic

  42. Specialized hand instruments A-ACCESS INSTRUMENTS B-DISSECTING/OPERATING INSTRUMENTS C-RETRIEVAL INSTRUMENTS

  43. Specialized hand instruments 5-10mm diameter instruments • Trocars & Ports---access devices • Graspers • Scissors • Dissectors • Clip applier,Knotting devices,Staplers • Cutting /coagulation – hooks,spatulas,balls,forceps • Irrigation suction tubes • Retrieval instruments

  44. Disposable vs Reusable instruments Conventional vs. Needle scopic /miniaturized instruments—2mm size

  45. Veress Needles

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