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
of a laparoscope: a telescopic rod lens system, that is
usually connected to a video camera (single chip or
KEYS OF LAPAROSCOPIC SURGERIES
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 non-
flammable, which is important because
 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
 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.

11-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 laproscopi
surgery”
Developed automatic insufflators and instruments
and carried out
1987-Phillipe Mouret, performed the first
1st lap appendicectomy.
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
- Hasson Cannula
Closed Technique
4. Veress Needle
5. Trocar Sheath
6. 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

 Gold Standard Abdominal Surgeries

• Laparoscopic cholecystectomy
• Laparoscopic fundoplication (Nissen’s)
• Laparoscopic adrenalectomy
• Laparoscopic obesity surgery
Excisional surgery, no r
reconstruction, trauma access
Co-Gold Standard
>trauma of excisionAbdominal
etc... Surgeries
• Laparoscopic
appendicectomy
• Laparoscopic colectomy
• Laparoscopic inguinal
hernia repair
• Laparoscopic splenectomy
• Laparoscopic
nephrectomy
PROBLEMS WITH LAPAROSCOPIC SURGERIES

• 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!
II. Postoperative
 Diathermy issues
 Medico legal &pain
Musculoskeletal conversion
due to
positioning
Off camera injury – delayed
presentation.
Referred pain – shoulder tip
Wound haematomas & bruising
DVT/PE

 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

• OPEN (a single, large conventional incision)

• 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

LAPAROSCOPIC RESECTION OF DIVERTICULITIS
only a few surgeons perform
this laparoscopically.
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
 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
LAPAROSCOPIC RESECTION FOR CROHN’S DISEASE
may not be appropriate.
Patients with Crohn’s 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 Crohn’s, 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 After 3 months the ileostomy is

incisions and closed, and
ileostomy look like this. 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 ( ¼ – ½ 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)
 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

Telescope
Lap Holes for gall bladder and Camera
surgeries
 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
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

 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
Technical difficulty of the procedure
patient
Unsuspected visceral injury Duration of the procedure
Difficulty in evaluating amount ofRate and volume of gas used for
blood loss insufflation
Gas embolism / Pneumothorax / Age of the patient
Surgical  coexistent&cardiopulmonary
intestinal vascular injuries
Emphysema disease
Lap chole mortality 0.1 - 1 per
Vessel trauma  Intravascular volume status of
1000
the patient (9)to laparotomy 1% ,
Conversion
bowel perforation
CBD injury & haemorrhage
Large vessel injury
Retroperitoneal haemorrhage
Gas embolus
Inguinal
Hernia
LAP APPENDICECTOMY

APPENDIX LOCATIONS
 LAP APPENDICECTOMY

APPENDICITIS
DISSECTION OF MESOAPPENDIX
 DIVIDING THE APPENDIX

Looped

Stapled
 COMPLICATIONS
Anesthetic Complications :

3. Inadequate Muscle Relaxation

Contraction of muscle during
procedure

Difficulty in Causes pain

during port
Pneumoperitoneum
insertion
Management
- Endotracheal intubation
- Pharmacological neuromuscular
 COMPLICATIONS OF LAPAROSCOPIC COLECTOMY
• 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.
5. Vessel Injuries :
- Mesenteric vessels, iliac vessels, epigastric
vessels and innominate vessels.
• Injury to Ureter
• Post operative bleeding
• Port site metastasis
 Anesthetic Complications :

3. Mask hyper ventilation

Prior to induction 100% oxygen is given by mask

ventilation

Hyperventilation

Distended stomach

Respiratory Dysfunction Liable to injury

during port inser.
Or
veress needle
inser.
Management
Nasogastric tube prior to surgery.
 Anesthetic Complications :
2. 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
13. Direct intracardiac insertion of needle
14. 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


 COMPLICATIONS DUE TO PNEUMOPERITONIUM

CO2 pneumoperitonium

(c) Gas specific effects (b) Pressure

Specific Effects

- Respiratory Acidosis Excessive

Pressure on IVC
- Hypercarbia
Reduced VR
Management
• Desufflation of abd. Reduced CO

• Vagolytic (Atropine) Rapid stretch

of peritoneal membrane
• Adequate volume Vasovagal
replacement
response
 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 :
13. Sequential compression stockings

14. Subcutaneous heparin or low molecular weight

 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
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