History of Laparoscopy 1902 - Georg Kelling, of Dresden, Saxony, performed the first laparoscopic procedure on dogs.
1910 - Hans Christian Jacobaeus of Sweden, reported the first laparoscopic operation on humans.
1980 - Patrick Steptoe from England, started to perform laparoscopic procedures in the operating room under sterile conditions.
1982 - The first solid state camera was introduced and this was the start of 'video-laparoscopy'.
1987 - Phillipe Mouret performed the first video-laparoscopic cholecystectomy in Lyons, France.
1994 - A robotic arm was designed to hold the laparoscope camera and instruments.
1996 - The first ever live broadcast of laparoscopic surgery via the Internet was performed.
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What is Laparoscopic Surgery?Laparoscopic surgery, also known as minimally invasive surgery (MIS) or ‘keyhole’ surgery is a modern surgical technique for carrying out operations in the abdomen through cannulae (also known as ports) which are channels into the body through small incisions. Using a video camera the surgeon is able to view the operative field without invasive surgery. The abdomen is usually insufflated with carbon dioxide gas.
By inflating the abdomen, the abdominal wall is elevated above the internal organs to create a working and viewing space for the surgeons.
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Why Laparoscopy?There are a number of advantages to operating on the patient with laparoscopic surgery versus open surgery. Some of these are: Less post-operative scarring
Reduced pain
Shorter recovery time
Less time spent in hospital to recover
Reduced hemorrhaging
Reduced risk of exposing internal organs to external contaminants
Quicker return to normal activities
Quicker return to work
Reduced wound complicationshttp://www.drsanjaykolte.in/
The Rise of Bariatric Surgery
One of the most common types of laparoscopic surgery is bariatric (obesity). Over the last decade there have been more advancements in bariatric surgery than there had been in the previous 50 years, fuelled largely by the growing obesity epidemic which began in the 1970s. The epidemic created the need for effective treatment of severe obesity and its co morbidities leading to the development of procedures such as gastric banding, gastric bypass and duodenal switch over the past decade. More recently, the advent of minimally invasive surgery in the mid-1990s accounted for the second wave of advances.
Before Laparoscopic Surgery
Before laparoscopy was practiced, surgeons operated using open/invasive surgery. This means cutting skin and tissues so that the surgeon has direct access to structures and organs. This involves more direct access than in minimally invasive procedures as the openings are bigger so the internal organs are openly exposed.
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Laparoscopic Surgery Cholecystectomy, Appendectomy & Colectomy
Vagotomy
Hiatal, Inguinal & Diaphragmatic hernia repair
Urological- Nephrectomy, Adrenelectomy & Prostatectomy.
OBG-Tubal surgeries,cystectomies,hystrectomies & various ablations (endometriosis)
Thoracoscopies
Neurosurgeries
Lumbar discectomies
Diagnostic procedureshttp://www.drsanjaykolte.in/
Advantages and DisadvantagesAdvantagesMinimal pain & illeusImproved cosmesisShorter hospital stay , faster recovery & rapid return to workNon muscle splinting incision & less blood lossPost op respiratory muscle function returns to normal more quicklyWound complications i.e. infection & dehiscence are lessLap surgery can be done as day care surgery
DisadvantagesLonger duration of surgeryLoss of 3D view, impaired touch sensationpoor dexterity, fulcrum effect, risk of visceral / vsl. Injury (may go unrecognised)Long learning curve for surgeons
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Fig. Demonstarting surgical incision Sites in lap cholecystectomy
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INSUFFLATING GAS OF CHOICE FOR LAPROSCOPY
Ideal insufflating gas of choiceColorless, non toxic, nonflammable, easily available, inexpensive, inert, readily soluble in blood and easily ventilated out of lungs
Why CO2 is the gas of choice for laparoscopy?
Nonflammable & does not support combustion
Highly soluble in blood because of rapid buffering in blood so risk of embolisation is small
Rapidly diffusible through membranes so easily removed by lungs
CO2 levels in blood & expired air can be easily measured & its elimination is augmented by increasing ventilation
CO2 is readily available & is inexpensive
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PROPERTIES OF OTHER GASES USED
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Gas Oswalds B:G solubility coef. complications
Air 0.017 Supports combustion, Gas embolism
Oxygen 0.036 do
Nitrogen Gas embolism
N2O 0.042 Supports combustion (if mixed with methane from bowel), Bowel distension, PONV, Explosion with cautery
CO2 0.49 Hypercarbia, Pain abdomen ,Shoulder tip pain, Arrythmia, Promotion of port site tumour growth, peritoneal irritant
He 0.00098 Embolism, diffusible, expensive
Argon Embolism, expensive
PHYSIOLOGICAL CHANGES
Physiologic effects seen with CO2 insufflations are
transient and derive from the body's reaction to
increases in intra abdominal pressure and CO2
absorption as it tries to achieve a new state of
homeostasis. People who are otherwise healthy will
tolerate laparoscopy well, while individuals with
underlying cardiopulmonary or renal diseases may
not tolerate prolonged CO2 insufflations.
Additionally, patient positioning, for example steep
Trendelenburg in prostatectomy, can exacerbate
cardiovascular alterations in laparoscopy.
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CARDIOVASCULAR RESPONSE
Cardiovascular changes vary with intra abdominal pressure, with higher pressures
associated with more significant changes than lower pressures. In any other case
healthy patients undergoing laparoscopy, the threshold intra abdominal pressure
that led to hemodynamic changes was 12 mm Hg. Those with underlying cardiac
disease will likely have a lower intra abdominal pressure threshold.
Heart rate may rise transiently in response to increases in SVR and arterial blood
pressure level to maintain cardiac output, but most studies have reported no
significant long-term changes in heartbeat with laparoscopy. In a tiny subset
(0.5%) of otherwise healthy patients, however, bradycardia and asystole can occur
during CO2 insufflation and pneumoperitoneum.
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RESPIRATORY RESPONSE
CO2 may be the gas of choice for laparoscopic surgeries because it is
noncombustible, extremely soluble, and readily eliminated with the lungs.
Despite the proven effectiveness and protection of CO2 for insufflation in
laparoscopy, the respiratory response to mechanical improves in intra abdominal
pressure as well as hypercapnia from absorption should be considered.
With CO2 insufflation and increases in intra abdominal pressure, the dintra
abdominal pressurehragm is pushed cephalad into the thoracic cavity,
constraining downward dintra abdominal pressurehragmatic excursion with
respiration. All round functional respiratory capacity, vital capacity, and
pulmonary compliance drop with boosts in intra abdominal pressure, and peak
airway and plateau pressures can enhance up to 50% and 81%, respectively.
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RENAL RESPONSE
Mechanistically, as intra abdominal pressure increases, its compressive effects on
the renal vasculature, the renal parenchyma, and the IVC will reduce effective
renal blood circulation (ERBF), cortical and medullary perfusion, and renal venous
outflow.
The renal effects are mild to negligible once the intra abdominal pressure is under
10 mm Hg, but as intra abdominal pressure reaches and exceeds 15 mm Hg,
there's a pressure-dependent decrease in the glomerular filtration rate (GFR),
ERBF, creatinine clearance, sodium excretion, and urinary output. In a typical
intra abdominal pressure of 15 mm Hg, urinary output decreases by as much as
63% to 64%, GFR by 21%, and ERBF by 26%. Despite this drop, however, there
are no long-term renal squeal, even in patients with pre-existing renal disease, and
pneumoperitoneum-induced renal failure does not occur.
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METABOLIC RESPONSE
Metabolic acidosis from CO2 absorption is the primary derangement with
laparoscopy. Systemic CO2 absorption and resultant metabolic consequences
differ depending on the patient's underlying respiratory status since the lung
eliminates absorbed CO2 buffered by the blood. In otherwise healthy patients,
an increase in minute ventilation is enough, but for individuals with COPD,
removal of CO2 is less capable, causing them to are afflicted by more major and
extended derangements in acid-base balance. As stated earlier, desufflation
might be necessary during a long laparoscopic procedure in patients with COPD
or interstitial lung condition.
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Causes for Paco2 during Laparoscopy
Absorption of carbon dioxide (CO2) from the peritoneal cavity
VA/Q mismatch: Increased physiologic dead space Abdominal Distention Position of the patient (e.g., steep tilt) Controlled mechanical ventilation Reduced cardiac output These mechanisms are accentuated in sick patients
Increased metabolism (e.g., insufficient plane of anesthesia)
Depression of ventilation by anesthetics (e.g., spontaneous breathing)
Accidental events CO2 emphysema (i.e., subcutaneous or body cavities) Capnothorax CO2 embolism (Selective bronchial intubation)
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ANAESTHESIA
PACDone in usual manner with special attention to cardiac & pulmonary system Investigations Complete hemogram RBS Na, K BUN, Creatinine Coagulation profile CXR, ECG BG, CM Special investigations ECHO PFT
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PREMEDICATION
NPO
Complete bowel preparation
Antibiotics as per surgical team
Awareness about post op shoulder tip pain
Written informed consent for laparotomy
Anxiolytics/antiemetics/H2 receptor antagonist/analgesic
Antisialagogue (glyco-P) and vagolytic may be administered at induction of
anaes.
DVT prophylaxis (rTn, pelvic Sx, long duration, malignancy, obesity)
Clonidine/ dexmetetomidine to decrease stress response
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MONITORING
HR
NIBP
Continous ECG
Pulse oximetry
Capnography
Temperature
Airway pressure
IAP
If required, ABG, precordial doppler,TEE may be instituted.
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CO2 s/c emphysema
Cause accidental extraperit insufflation (malpositioned verris needle) deliberate extraperit insufflations- retroperit surg,TEPP,fundoplication, pelvic lymphadenectomy
Diagnosis ETCO2 -cannot be corrected by adjusting ventilation even after plateau reached ABG, Palpation
Treatment Stop CO2 insufflation, interrupt lap temporarily CMV continued till hypercapnia resolves Resume lap at low insufflation P thereafter
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Pneumothorax / pneumomediastinumCause pleuroperitoneal communications (R>L)Diaph defects( aortic, esophageal, GE jn surg)Rupture of preexisting bullaePerf falciform ligament Diagnosis –airway P, sudden ↓Sp O2 , sudden ↓/ ETco2, Abnormal motion of hemidiaph by laparoscopist
PNEUMOTHORAX
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CAPNOTHORAX ET CO2 (may fall later) V CO2, PaCO2,
AIR PNEUMOTHORAX↓ET CO2 (due to ↓CO)
Stop N2O 100 % O2IAPPEEPThoracocentesis not neededInform surgeon
Do not apply PEEPMandatory
CO2 embolism (rare but potentially fatal)Risk factors hysteroscopies, previous abd surg, needle/Trocar in vsl
Consequences- GAS LOCK in vena cava ,RA → ↓ VR →© collapse - Ac RV HTN → opens foramen ovale → paradoxical gas embolism DiagnosisHR, ↓BP, CVP, hypoxia, cyanosis, ET CO2 biphasic change, Δa ETco2 ECG- Rt heart strain, TEE, pulm art. Aspiration of gas/ foamy bld from CVP line
TreatmentRelease source (stop co2 + release pneumoperit)position – steep head low + durant position stop N2O + 100%O2HyperventilationCVP/PA catheter to aspirate CO2Cardiac massage may break embolus- rapid absorptionHyperbaric o2 - cerebral embolism
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Endobronchial intubation
Due to cephalad movement of diaph with head down tilt and IAP
Diagnosis - Sp O2 ↓ airway P
Treatment – Repositioning of ETT
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Aspiration
Mendelson syndromeAt IAP>20 mmHg
Changes in LES due to IAP that maintain transsphincteric P gradient + head down position protect against entry of gastric content in airways
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Nerve injuries
Prevented byavoid overextension of arms
padding at P points
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Laparoscopy in children
Physiological changes = adultsPaco2 ETco2 increase but ETco2 overestimates Paco2Co2 abs more rapid and intense due to larger peritoneal SA / body wt.More chances of trauma to liver during trocar insertionMore chances of bradycardia , maintain IAP to as low as possible
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Laparoscopy in pregnancy
Indications- appendicectomycholecystectomy Risk – preterm labour, miscarriage, fetal acidosisTiming – II trimester (< 23 wk)Lap technique – HASSANS techSpecial considerations prophylactic- antithrombolytic measures + tocolyticsoperating time to be minimisedIAP as low as possibleContinous fetal monitoring (TVS)Lead shield to protect foetus if intraop cholangiography needed
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About Dr. Sanjay KolteDNB, FMAS(AMASI IDIA), F.C.P.S.(Mumbai)
MBBS - OCTOBER 1995-BHARATI VIDYAPEETH'S MEDICAL COLLEGE, PUNE, INDIAFCPS (General Surgery) - SEPTEMBER 2000, MUMBAI, INDIA
(FELLOW OF COLLEGE OF PHYSICIANS AND SURGEONS)
DNB (General Surgery) - MAY 2001-KING EDWARD MEMORIAL HOSPITAL, PUNE, INDIA (DIPLOMATE OF NATIONAL BOARD, NEW DELHI)MNAMS - MEMBER OF NATIONAL ACADEMY OF MEDICAL SCIENCES, NEW DELHI
Contact Details:Laparoscopic Surgery Clinic, Parihar Chowk, Aundh, Pune, Maharashtra 411007Mobile : 91+98 22 00 94 90Email : [email protected]
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