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

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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