LAPAROSCOPIC ABDOMINAL SURGERIES

WHAT IS LAPAROSCOPIC SURGERY

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

KEYS OF LAPAROSCOPIC SURGERIES 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 nonflammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures.

HISTORY OF LAPAROSCOPY Early 1800 CYSTOSCOPES USED 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 Desormeaux, French surgeon first introduced the Lichtleiter (Simple tube about candlelight) into a patient. Considered as the "Father of Endoscopy lead to develop Cystoscopes 1876-Maximilian Nitze, modified Edison'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 Contd EARLY 20th CENTURY LAPAROSCOPY INTRODUCED 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.

1911-Jacobeus of SWEDEN

1st human laproscopy

HISTORY OF LAPAROSCOPY Contd 1938-Veress, of Hungary, developed the spring-loaded needle. Adapted Modification of Veress needle used to achieve pneumoperitoneum

1978-Hasson blunt mini-laparotomy which permits direct visualization of trocar entrance into the peritoneal cavity

HISTORY OF LAPAROSCOPY Contd 1960-1970-Semm Father of modern laproscopic surgery Developed 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

INSTRUMENTS OF MODERN LAPAROSCOPY Fibreoptic scopes Rod lens system Fiber Optic cables Light sources & video systems

New Miniaturized
Aspirator Dissecting forceps Grasping instruments Scissors Clip applicator s Staples Sutures / needles Needle holder Cautery (mono & bi polar)

New vascular control

Harmonic Scalpel Ligatures

ABDOMINAL ACCESS INSTRUMENTS Open Technique

1.

Hasson Cannula

Closed Technique
1. 2. 3.

Veress Needle Trocar Sheath assemblies

ADVANTAGES OF LAPOROSCOPIC SURGERIES Less pain than laparotomy Exposure 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

Gold Standard Abdominal Surgeries Laparoscopic cholecystectomy Laparoscopic fundoplication (Nissens) Laparoscopic adrenalectomy Laparoscopic obesity surgery Excisional surgery, no r reconstruction, trauma access >trauma of excision etc... Co-Gold Standard Abdominal Surgeries Laparoscopic appendicectomy Laparoscopic colectomy Laparoscopic inguinal hernia repair Laparoscopic splenectomy Laparoscopic nephrectomy

PROBLEMS WITH LAPAROSCOPIC 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! Diathermy issues Medico legal & conversion
II. Postoperative

Musculoskeletal pain due to positioning Off camera injury delayed presentation. Referred pain shoulder tip Wound haematomas & bruising DVT/PE Port site hernias Longer procedure

DISADVANTAGES OF LAP SURGERIES 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

SURGERY OF THE COLON AND RECTUM

Surgery on the large intestine can be performed in two ways 1. OPEN (a single, large conventional incision) 2. LAPAROSCOPIC ( several very small incisions)

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

LAPAROSCOPIC COLON AND RECTAL SURGERIES

Laparoscopic Resection for Polyps

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 RESECTION OF DIVERTICULITIS 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 COLORECTAL POLYPS 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 FOR CROHN S DISEASE Patients with Crohns 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 Crohns, 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 ( inch) Carbon Dioxide (CO2) gas is pumped into the abdomen through the port (canula) to puff-up 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.

How is Laparoscopic Colon Resection Performed?

This shows the canulas or tubes that are inserted to allow special surgical instruments to be used inside the abdomen.

How is Laparoscopic Colon Resection Performed?

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

RISKS OF COLON LAP SURGERIES 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 Death

GALL BLADDER LAP SURGERIES/ LAP CHOLECYSTECTOMY

Grasping and Dissecting Instruments

Lap Holes for gall bladder surgeries

Telescope and Camera

GALL BLADDER LAP SURGERIES/ LAP CHOLECYSTECTOMY

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

LAP CHOLESYSTECTOMY

DELIEVERING THE GALL BLADDER

Possible complications of gallbladder surgery

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

ADVANTAGES OF LAP CHOLECYSTECTOMY

75% were significantly better after laparoscopic cholecystectomy when compared to open surgery Significantly lower incidence of atelectasis and better oxygenation Diaphragmatic function is also significantly impaired after Laparoscopy Post-op respiratory function recovery is slower in elderly, obese, COPD 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

DISADVANTAGES OF LAP CHOLECYSTECTOMY

Physiological consequences Cardiovascular Effects

Pneumoperitoneum Raised intra abdominal pressure Raised intra-abdominal pressure Hypercarbia Operative position of the patient Intra-operative position of the patient Technical difficulty of the procedure Duration of the procedure Unsuspected visceral injury Rate and volume of gas used for insufflation Difficulty in evaluating amount of blood loss Age of the patient Gas embolism / Pneumothorax / Surgical coexistent cardiopulmonary disease Emphysema Intravascular volume status of the patient (9) Vessel trauma intestinal & vascular injuries Lap chole mortality 0.1 - 1 per 1000 Conversion to laparotomy 1% , bowel perforation CBD injury & haemorrhage Large vessel injury Retroperitoneal haemorrhage Gas embolus GI Tract injury

Inguinal Hernia

LAP APPENDICECTOMY

APPENDIX LOCATIONS

LAP APPENDICECTOMY

APPENDICITIS

DISSECTION OF MESOAPPENDIX

DIVIDING THE APPENDIX

Looped

Stapled

COMPLICATIONS
Anesthetic Complications :
1.

Inadequate Muscle Relaxation

Contraction of muscle during procedure

Difficulty in Pneumoperitoneum

Causes pain during port

insertion

Management
-

Endotracheal intubation Pharmacological neuromuscular blockade Positive pressure ventilation

COMPLICATIONS OF LAPAROSCOPIC COLECTOMY

1.

2.

3. 4. 5.

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. Vessel Injuries : - Mesenteric vessels, iliac vessels, epigastric vessels and innominate vessels. Injury to Ureter Post operative bleeding Port site metastasis

Anesthetic Complications :
2.

Mask hyper ventilation

Prior to induction 100% oxygen is given by mask ventilation 100% Hyperventilation Distended stomach Respiratory Dysfunction Management Nasogastric tube prior to surgery. surgery. Liable to injury during port inser. Or veress needle inser.

Anesthetic Complications :
3.

Air Embolism CO2 used for pneumoperitonium Gets absorbed into circulation Embolus may form and block pulmonary circulation

Loud and clear murmur heard in (R) atrium and (R) ventricle (Mill-Wheel murmur)

Management 1. Direct intracardiac insertion of needle 2. Central venous catheter.

Management Continuous I/V assess Emergency cart with all resuscitative drugs and defibrillator. One should be prepared with Oxygen Suction Bag and mask ventilation Oral and nasal pharyngeal airway, ET tubes of various sizes. Sphygmomanometer Electrocardiograph Pulse oxymeter

COMPLICATIONS DUE TO PNEUMOPERITONIUM

CO2 pneumoperitonium
(a)

Gas specific effects Respiratory Acidosis Hypercarbia

(b) Pressure Specific Effects Excessive Pressure on IVC Reduced VR

1. 2.

Management Desufflation of abd. Vagolytic (Atropine) Adequate volume replacement

Reduced CO Rapid stretch of peritoneal membrane Vasovagal response Bradycardia , occasionally hypotension

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 Deep vein thrombosis Pulmonary Embolism Management : 1. Sequential compression stockings 2. Subcutaneous heparin or low molecular weight heparin

CONCLUSION
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

T H A N K Y O U

Q u e s t i o n s

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, pulmonary function, 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 Vs Mini Cholecystectomy. A National Survey of 4292 hospitals and analysis 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.