I . ARNIF

Principles of Laparoscopic and Robotic Surgery

Pembimbingdr. M Iqbal Rivai, SpB KBD

Definition

Modern technology and surgical innovationMinimal somatic and psychological traumaShorten operating time, shorten hospitality,

faster recuperation

Extent of minimal access surgery

LaparoscopyThoracoscopyEndoluminal endoscopyPerivisceral endoscopyArthroscopy and intraarticular joint surgeryCombined approach

Surgical trauma in open, laparoscopic and robotic surgery

Mechanical and human retractor additional trauma

Exposure to atmoshere evaporationAdhesionHandling intestines adynamic ileus

Limitation of minimal access surgery

Operate remoteTwo dimensional viewHand-eye coordination problems (technically

demanding)No tactile feedback (laparoscopic USG)“convert to an open operation isn’t a

complicationArterial bleedingLarge pieces of resected tissue

Improvement

Hand assisted laparoscopic surgeryUltrasonic dissection, tissue fusion device,

tissue removal have been utilisedCurrent units combine three or four functionsThree dimensional imagingKnot tying

Robotic surgery

Mechanical deviceAutomatic physical tasksDirect human supervisionRedefined program/general guidelinesArtificial intelligence techniques

Laparoscopic limitation robotic surgeryBetter visualisationelimination hand tremor, improved

manoeuver (robotic wrist)Large external movement limited internal

movement (robotic hand)Ergonomic place, less stress, higher

concentration

preoperative evaluation

HistoryExaminationPremedicationProhylaxis against thromboembolismUrinary catheters and nasogastric tubesInformed consent

Theatre set up and tools

Key to surgery’s smooth runningNew theatre designed with moveable tools

come down from ceilingImage quality is vitalDisposable equiments more availableSimple designs are now being studied

General intraoperative principles

Creating a pneumoeritoneum (closed, open)

Preoperative problemsPrevious abdominal surgeryobesity

Operative problems

Intraoperative perforation, bleding (operative)

*extra ports may be requiredHandle bleeding prevent it from happeningBleeding from major vessel : use fine tip

grasper (electrocautery/clip)Good suction and irrigation

Bleeding from gallbladder perform dissection in correct plane

Bleeding from trocar site upwards and lateral pressure with the trocar

pressure (folley balloon catheter), and suturesBlood clots “avoid” by careful dissection,

identification of arteryRoutine 5000-7000 units heparin per litre of

irrigation fluids, small pool irrigation fluid, suction

principles of electrosurgery during laparoscopic surgery

Electrosurgical injuries are potentially serious, occur by using monopolar diathermy (1-2 per 1000 operations)

Usually delayed recognised as a fever and abdominal pain 3-7 days after surgery

Bipolar diathermy is safer

Postoperative care

Complaints: upper abdominal pain (dull), nausea, pain around the shoulder

Suggestions: local anaesthetic, leave 1 litre saline,

Investigation: blood count, liver function, ultrasound

No problems discharge within 24 hours with instruction to return if no satisfactry progress

Nausea. Avoid opioid analgesiaShoulder tip painAbdominal painAnalgesiaOrogastric tubeOral fluidsOral feeding 4-6 hours after surgeryUrinary catheterdrains

Discharge from hospital

On the day of surgery/following morningAbdominal pain/severe symptoms return to

hospitalSutures non absorbable in 7 daysMobility and convalescence. move A.S.A.p

Common laparoscopic procedures

Certain emergency (stable patient) : diagnostic, perforated duodenal ulcer repair, appendicectomy, intestinal obstruction by adhesions, strangulated hernia repair

Robotic disadvantages

Increased costIncreased set up of the system and operating timeSosioeconomic implicationsSignificant risk of conversion to convensional

techniquesProlonged learning curveMultiple repositioning of the arms can cause

traumaHaemostasisCollision of the robotic arms in extreme positions

Further developments

Natural Orifice Translumenal endoscopic surgery (NOTES)

Single Incision Laparoscopic surgery (SILS), Laparoendoscopic singlesite surgery (LESS), Single port Access (SA)

NOTES

SILS

The future

No change in nature of diseaseTraining is a key to progressRobotic surgery now available not only for

assisting, but also for aiding in the perioerative management

Terima Kasih