Principles of Laparoscopic Surgery

Dr Khalid Javeed Khan FCPS FRCS Associate Professor Surgery Fatima Jinnah Medical College

If you are thinking one year ahead, you plant rice. If you are thinking twenty years ahead, you plant trees. If you are thinking hundred years ahead, you educate people.

Evolution of Laparoscopic Surgery

The use of speculum type intracorporeal viewing devices dates to the Greco-Roman period, when Hippocrates(c.460377 BCE) is known to have performed anoscopy for diagnosis of fistula and hemorrhoids. In 1805 Phillip Bozzini developed the Lichtleiter (light conductor). This instrument employed a candle, mirrors and various specula for viewing inside The next major advance came in 1853 when Antonio Desormeaux developed his versatile endoscope that burned gazogene(alcohol and turpentine) as a light source

Evolution of Laparoscopic Surgery

Laparoscopy is a combination of two Greek words, Laparo, the flank and skopein, to examine First performed in 1901 by George Kelling of Germany when he entered the abdominal cavity of a dog after air insufflation

Eight years later Hans Christians(sweden) reported first laparoscopy and thoracoscopy in humans
In United states Bertram bernheim was the first to perform laparoscopy in 1911 The first atlas and textbook of laparoscopic surgery was written in Germany by Roger Korbsch In 1927

The technology development

Heinz kalk of Germany (hepatologist) in 1927 introduced forward viewing scope which improved operator orientation The use of CO2 to create pneumoperitoneum was first recommended in 1924 by Richard Zollikofer(swiss)

The preferred route of insufflation was the Veress needle introduced by Janos Veress of Hungary In 1938

The technology development

Since 1930 laparoscopic tubal ligation have been performed by the gynecologists The 1960s and 1970s brought two major developments, the first was the introduction of the rod lens system in 1960 by Harold Hopkins of England, the second in 1963 was cold light transmission via fiber optic cables developed by gastroenterologist Hirschowtz in Ann arbor, Michigan. The combination of these two technologies positioned laparoscopy as a viable therapeutic modality for a variety of problems

The technology development

The automatic insufflator was designed by gynecologist and engineer Karl semm in 1966 and greatly reduced the adverse effects of pneumoperitoneum The technique of direct visualization of the peritoneal cavity was introduced by Hasson in 1974

Laparoscopic surgery

First laparoscopic cholecystectomy was performed in 1988 by Mouret of France No surgical procedure is without risk. Despite the minimally invasive nature of laparoscopic surgery, the potential for adverse outcome is present and should be taken as seriously as in a traditional open procedure. Patient selection and preparation for a laparoscopic procedure is the first step in ensuring successful outcome

Preoperative evaluation

A careful history and physical examination are the cornerstones of patient selection for surgery. Preexisting that predispose patient to both anesthetic and surgical complications must be identified. Signs and symptoms suggestive of cardiac or pulmonary disease should be specifically sought. Preoperative laboratory evaluation depends on the nature of surgery, the patients past medical history, and the preferences of both the surgeon and the anesthetist.

In general this may include B/C, S/E, urinalysis. Coagulation studies if required, and EKG and chest X-ray for patients above 40

Preoperative evaluation

It is important to carefully evaluate the patient with known or suspected pulmonary disease prior to undertaking a laparoscopic procedure, as pneumoperitoneum and hypercarbia may be poorly tolerated Pulmonary function tests and arterial blood gases determination may be helpful in deciding It is important to determine the baseline pCO2 in patients with known pulmonary disease so that the extent of hyperventilation can be better evaluated intra operatively

The cardiac risk factors need to be carefully evaluated

Preoperative evaluation

The past surgical history and the location of prior incisions should be specifically considered as this will aid in the planning of access method and trocar placement The patient should be specifically examined for an umbilical hernia or urachal cyst The ability to abduct hips and arms should be assessed The presence of ascites will effect abdominal access and may complicate the postoperative course if the fluid becomes infected or leaks from the trocar site

Preoperative evaluation

Patients with history of DVT should be carefully evaluated preoperatively, as many procedures are lengthy, require the reverse Trendelenberg position, and can have significant inferior vena cave compression secondary to the pneumoperitoneum. All patients should have compression stockings in place before the induction of general anesthesia, those at high risk may need additional measures including pneumatic compression devices

Contraindications to Laparoscopic surgery

Hypovolemic shock as the patient is less prepared to tolerate the further decrease in venous return. In addition these patients will benefit from the most expeditious operation, as their end organ perfusion will only be further challenged by longer anesthesia A laparoscopic procedure is contraindicated in patients with significant ongoing abdominal bleeding due to both hypovolemia and technical issues

Contraindications to Laparoscopic surgery

Hemodynamic instability for any reason, poor candidates for laparoscopy. The effects of pneumoperitoneum as well as the extremes in patient positions during laparoscopy will be poorly tolerated by patients already compromised Massive abdominal distension- in patients with extremely dilated intestines it is unsafe to attempt to establish pneumoperitoneum due to likelihood of bowel puncture Inability to tolerate a laparotomy

Surgeon inexperience

Relative Contraindications to Laparoscopic surgery

General peritonitis of uncertain origin, patients with diffuse peritonitis, especially when the etiology is unclear, are not ideal candidates for a laparoscopic exploration Advanced cardiopulmonary disease, the cardiopulmonary effects of pneumoperitoneum and the duration of the procedure may make an open approach more suitable for these patients Advanced pregnancy, particularly in the lower abdomen are difficult in near term patients

Uncorrectable coagulopathy
Portal hypertension

Laparoscopic suite

A dedicated laparoscopic suite in the operating room is becoming increasingly popular Each suite carries the essential basic equipment for laparoscopic surgery, whether they are built in to the actual room suspended from the ceiling or are mounted on the mobile carts video towers) Appropriate room setup and patient positioning are also extremely important The entire operating team of nurses, technicians, surgeons and anesthetists must be familiar with the demands of laparoscopic patient, with the operating room and equipment

Basic laparoscopic equipment

The insufflation system Imaging system Irrigation/aspiration unit Electrocautery unit

Insufflation system

The insufflation system allows the surgeon to create a working space in the abdomen in which to see and operate Pneumoperitoneum is maintained throughout the procedure and it should be directly controlled by the surgeon or the circulating nurse The insufflation system should be continuously in direct view so the surgeon can monitor its minute-to-minute function

Insufflation system
The major components of an insufflation system are the insufflant, the insufflator, and the insufflation needle or trocar

For laparoscopic procedures the insufflant medium is gas. Various gases have been evaluated including, air, oxygen, carbon dioxide, nitrous oxide and inert gases such as xenon, argon and krypton. Air and inert gases are insoluble in blood and therefore carry a risk of air embolism.

Oxygen is flammable and so not used

CO2 is not flammable and rapidly dissolves in blood

Insufflation system

The insufflator is a device that allows the flow of gas from a cylinder into the space being insufflated. It adjusts the rate of flow It maintains a required intraperitoneal pressure It displays the total amount of gas insufflated It also indicates the pressure in the cylinder

Insufflation system

Most units offer flow rate 1-5 L/min(low), 6-10 L/min(medium) 11-15 L/min(high) Pressure should be maintained between 10 and 15mmHg during laparoscopic procedures At high pressure >25mmHg the risk of gas absorption and air embolism is greatly increased There is increased risk of decreased venous return resulting from compression of the IVC and impaired ventilation secondary to pressure on the diaphragm

Imaging system

The quality of the imaging system is extremely important as it functions as the eye of the operating team. Components include the laparoscope, camera, monitor and light source The laparoscope allows light transmission into the peritoneal cavity to the surgical field and image transmission out of the peritoneal cavity to the camera. Most laparoscopes consist of a rigid rod lens imaging system, an eyepiece and a flexible fiber optic light conducting cable.

Imaging system

Common sizes are 10 and 5mm Larger sizes are capable of transmitting greater amounts of light, a wider field of vision and better image resolution Both sizes are available with either straight or angled lenses, 30-degree, 45-degree and 50-degree The camera magnifies the endoscopic view by 15-fold allowing high resolution imaging of anatomical details

Imaging system

The camera attaches to the eyepiece of the laparoscope and transmits digitized optical information from the scope via cable to the video box, the digital image data are then reconstructed and displayed on the monitor The camera should be focused , and the camera/video system should be white balanced to optimize image color representation Insertion of a room temperature laparoscope into the peritoneal cavity will result in fogging of the lens

Irrigation/aspiration system

In any laparoscopic procedure a surgeon will benefit by using this device to keep the field clean The irrigation fluid can flow by gravity, but the use of a pressurized bag provides more active flow The most common irrigants are normal saline with 5000 units heparin added per liter or lactated ringer solution

Electrocautery

Tissue cutting and coagulation is best achieved with electrocautery unit, controlled by foot pedal by the surgeon The most commonly used tip configurations are spatula, dissectors, and right angled L hook, others include scissors, dissectors and graspers All the above are insulated with a thin nonconductive coating

Laparoscopic procedures

Gastrointestinal tract, Laparoscopic assisted esophagectomy Laparoscopic cardiomyotomy for achalasia Fundoplication for GORD Bariatric surgery Gastrectomy and small bowel surgery Appendectomy Colon surgery Adhenolysis and diagnostic surgery

Laparoscopic procedures

Hepatobiliary system Cholecystectomy Liver and bile duct procedures Pseudocyst and pancreatic abscess Laparoscopic bypass procedures Splenectomy

Laparoscopic procedures

Endocrine surgery Adrenalectomy Enucleation of benign pancreatic islet tumors Whipples procedure Endoscopic neck surgery

Laparoscopic procedures

Inguinal hernias Ventral hernias Nephrectomy Ureter and bladder Hysterectomy Myomectomy Tubal ligation/ectopic pregnancy

The end