laproscopic surgery
DESCRIPTION
Rawalpindi Medical collegeTRANSCRIPT
Principal of Principal of Laparoscopic Laparoscopic
SurgerySurgeryPROFESSOR HAMID HASSANPROFESSOR HAMID HASSAN
PROFESSOR OF SURGERYPROFESSOR OF SURGERY
SURGICAL UNIT – I, RGHSURGICAL UNIT – I, RGH..
Minimal Access Surgery is the Minimal Access Surgery is the marriage of the modern marriage of the modern technology and Surgical technology and Surgical Innovation.Innovation.
AimsAims
Minimal Somatic traumaMinimal Somatic trauma
Minimal Psychological TraumaMinimal Psychological Trauma
lesser Hospital Staylesser Hospital Stay
Faster recuperationFaster recuperation
CategoryCategory
Laparoscopy.Laparoscopy.
Thoracoscopy.Thoracoscopy.
Endoluminal endoscopy.Endoluminal endoscopy.
Perivisceral endoscopy.Perivisceral endoscopy.
Arthroscopy and Intra-articular Surgery.Arthroscopy and Intra-articular Surgery.
Combined Approach.Combined Approach.
Dimension of Dimension of Laparoscopic SurgeryLaparoscopic Surgery
Diagnostic Laparoscopic SurgeryDiagnostic Laparoscopic Surgery Non Specific Abdominal PainNon Specific Abdominal Pain B.A.TB.A.T Staging of Intra abdominal MalignancyStaging of Intra abdominal Malignancy Secondary Infertility in FemalesSecondary Infertility in Females
Therapeutic Laparoscopic SurgeryTherapeutic Laparoscopic Surgery Lap. CholecystectomyLap. Cholecystectomy Lap. SpleenectomyLap. Spleenectomy Lap ThyroidectomyLap Thyroidectomy Lap. Ligation of Varicose vein perforatorsLap. Ligation of Varicose vein perforators Lap. Cardiac bypass surgeryLap. Cardiac bypass surgery Lap. Biopsy taken from Lungs and LiverLap. Biopsy taken from Lungs and Liver
Different Instrument Different Instrument use in use in
Laparoscopic Laparoscopic SurgerySurgery
Blunt Tip TrocarBlunt Tip Trocar
Blunt tip
Trocarsleeve
Adjustableolive
Desufflationlever Locking
button
ObturatorhandleStopcockCam
Suturetie point
Dilating Tip Surgical TrocarDilating Tip Surgical Trocar
*trademark
Curved Intraluminal Staplerswith Detachable Head
CONVENTIONAL LIGATIONLIGACLIP* Multiple Clip Appliers
ABSOLOK* EXTRA Absorbable Single Clip SystemLIGACLIP* EXTRA Single Clip System
Skin Stapler
PROXIMATE* Linear Cutters
Preoperative Preoperative EvaluationEvaluation
AimsAims The patient is fit for surgeryThe patient is fit for surgery The patient is fully informed and The patient is fully informed and
consentedconsented Operative difficulty is predicted where Operative difficulty is predicted where
possiblepossible Appropriate theater time and facilities Appropriate theater time and facilities
availableavailable
HistoryHistory
ExaminationExamination
PremedicationPremedication
Prophylaxis against ThromboembolismProphylaxis against Thromboembolism
Informed consentInformed consent
Urinary catheter and NG tube if needed.Urinary catheter and NG tube if needed.
General IntraoperativeGeneral Intraoperative
PrinciplesPrinciples
Anesthesia
Inst
rum
ent
Table
Ass
ista
nt
Scru
b
Nurs
e
Monitor
MayoStand
Surg
eon
Operation Theater Setup
Creating a Creating a PneumoperitoniumPneumoperitonium
Preoperative ProblemsPreoperative Problems
Previous Abdominal SurgeryPrevious Abdominal Surgery
ObesityObesity
Operative ProblemsOperative Problems
Perforation of hollow viscusPerforation of hollow viscus
BleedingBleeding
From Major VesselFrom Major Vessel
From Gall Bladder BedFrom Gall Bladder Bed
From Trocar SiteFrom Trocar Site
How to Evacuate the Clot ?How to Evacuate the Clot ?
Principal of Principal of Electrosurgery during Electrosurgery during Laparoscopic SurgeryLaparoscopic Surgery
Monopolar diathermyMonopolar diathermy
Bipolar DiathermyBipolar Diathermy
Electrical Injuries unrecognized at the time of operation patient present after about 3 -7 days with abdominal pain and fever.
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95 E
thic
on E
ndo-
Sur
gery
, Inc
..
Electrosurgery
Causes of injuryCauses of injury
Inadvertent touching and grasping.Inadvertent touching and grasping.
Direct coupling between the tissue and Direct coupling between the tissue and the instrument.the instrument.
Break in insulation.Break in insulation.
Direct sparking to bowel from the Direct sparking to bowel from the diathermy probe.diathermy probe.
Passage of current to the bowel from Passage of current to the bowel from recently coagulated tissue.recently coagulated tissue.
Postoperative Postoperative CareCare
NauseaNausea
Shoulder PainShoulder Pain
Abdominal PainAbdominal Pain
AnalgesiaAnalgesia
Oral fluidsOral fluids
Oral feedingOral feeding
DrainsDrains
Mobility and ConvalescenceMobility and Convalescence
Discharge from the HospitalDischarge from the Hospital
Skin Sutures.Skin Sutures.
Principal Of Principal Of
Common Common
Laparoscopic Laparoscopic
ProcedureProcedure
Laparoscopic CholecystectomyLaparoscopic Cholecystectomy
Hartmann’s pouch(infundibulum)
Gallbladder
Fundus
Duodenum
Duodenal wall
Ampulla of Vater
Hepatic ductsLiver margin
Common hepatic duct
Sphincter of Oddi
Common bile duct
Pancreatic duct
Cystic duct
Duodenal papilla
LiverPortal vein
Ligamentum teres
Common hepatic duct
Cystic artery
Gallbladder
Right hepatic artery
Cystic duct
Common bile duct
Gastroduodenal artery
Superior mesenteric vein
Superior mesenteric artery
Pancreas
Splenic artery
Celiac trunk
Abdominal aorta
Left gastric artery
Left hepatic artery
Proper hepatic artery
Common hepatic artery
Video monitorLight sourceCameraVCRSuction unitCO2 insufflator Anesthesia
Surg
eonA
ssis
tant
Instrumentstand
Electrocautery unitSuction unit
5mm trocarmidclavicular
5mm trocaranterior axillary
5mm or10/12mm trocarsubxiphoid
10/11mm or10/12mm trocarumbilicus
Port Placement
Laparoscopic Laparoscopic Cholecystectomy (Hook)Cholecystectomy (Hook)
Use the hook blade to Use the hook blade to dissect cystic duct and dissect cystic duct and arteryartery
Ligate with clipsLigate with clips
Transect with hook bladeTransect with hook blade
Use side of hook for Use side of hook for coaptive coagulation coaptive coagulation prior to transactionprior to transaction
Cavitationally assisted dissection off the liver bed
Back or side of hook Back or side of hook blade for small bleeders blade for small bleeders on the liver bedon the liver bed
Laparoscopic Inguinal Laparoscopic Inguinal HerniaHernia
Trans Abdominal Preperitoneal repairTrans Abdominal Preperitoneal repair
Extraperitoneal repairExtraperitoneal repair
Rectusabdominis
Medialumbilicalligament
Hesselbach’striangle
Lacunar(Gimbernat’s)
ligament
Urinarybladder
Vas deferens
Ureter
Sacralpromontory
Inferiorepigastricvessels
Internalinguinalring
Cooper’sligament
Iliopubictract
Testicularvessels
Externaliliacvessels
Cecum
Laparoscopic Laparoscopic Antireflux SurgeryAntireflux Surgery
Esophagus
Phrenoesophagealligament
(ascending orupper limb)
Respiratorydiaphragm
Subhiatalfat ring
Phrenoesophagealligament
(descending limb)
Visceralperitoneum
Phrenoesophageal ligament(ascending or upper limb)
Phrenoesophagealligament(descending limb)
Visceralperitoneum
Infradiaphragmaticfascia
Fundusof stomach
Ligaments of the Esophageal Hiatus(anterior view)
Anesthesia
Monitor Monitor
Inst
rum
ent T
able
Ass
ista
nt
FirstA
ssistant
Surgeon
Nissen Fundoplication
5 or 10/12mm trocaroperating port
5 or 10/12 mm trocarliver retraction
umbilicus
10/12mm trocaroperating port
10/12mm trocarstomach retraction
10/12mm trocarcamera port
Port Placement
NISSEN FUNDOPLICATIONNISSEN FUNDOPLICATION
Fig. 1Liver
retracted
Fig. 2Crura closed
Fig. 3Short gastric vessels
divided
Fig. 4Wrap created
Fig. 5Wrap fixated
Laparoscopic Laparoscopic SpleenectomySpleenectomy
Greater curvatureof vascular arcade
Stomach(posterior surface)
Caudate lobeof liver
Proper hepatic artery
Inferior vena cava
Gastroduodenal artery
Right gastroepiploicartery
Duodenum
Greater omentumAnterior superiorpancreaticoduodenalartery
Common hepatic artery
Celiac trunk
Pancreas
Left suprarenalgland
Superior poleof kidney
Leftgastroepiploicartery
Spleen
Splenic artery
Greater omentum
Left gastric artery
Spleenic Artery Anatomy
Division of short gastric vesselsDivision of short gastric vessels
Division of short gastric vesselsDivision of short gastric vessels
Division of short gastric vesselsDivision of short gastric vessels
Dissection of Spleenic VesselsDissection of Spleenic Vessels
Ligating Spleenic Artery
Divided splenic artery and veinDivided splenic artery and vein
Exposure of Inferior Pole LigamentsExposure of Inferior Pole Ligaments
Direct Approach to HiliumDirect Approach to Hilium
Division of Hilum with Division of Hilum with Endoscopic StaplerEndoscopic Stapler
Completion of SpleenectomyCompletion of Spleenectomy
Spleen Placed in BagSpleen Placed in Bag
Bagged SpleenBagged Spleen
Removed SpleenRemoved Spleen
Cannula SitesCannula Sites
Future Of Future Of LaparoscopicLaparoscopic 1. Gas less Laparoscopic Surgery2. Hand assisted Laparoscopic Surgery3. Natural Orifice Transluminal Endoscopic Surgery (NOTES)
is being investigated as an alternative to laparoscopy. 4. Laparoscopic surgery utilizing the computer robot system