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Diagnostic Laparoscopy
Diagnostic la/arosco/y is a -ini-ally in1asi1e surgical /rocedure that allo2s the 1isual e3a-ination o4 intra abdo-inal organs in order to detect /athology0 5he 1ideo i-age o4 the li1er, sto-ach, intestines, gallbladder, s/leen, /eritoneu-, and /el1ic organs can be 1ie2ed on a -onitor a4ter insertion o4 a telesco/e into the abdo-en0 (ani/ulation and bio/sy o4 the 1iscera is /ossible through additional /orts0
Diagnostic la/arosco/y 2as 4irst introduced in 1!01, 2hen 6elling, /er4or-ed a /eritoneosco/y in a dog and 2as called 7celiosco/y80 9 :2edish internist na-ed ;acobaeusc is credited 2ith /er4or-ing the 4irst diagnostic la/arosco/y on hu-an in 1!100 <e described its a//lication in /atients 2ith ascites and 4or the early diagnosis o4 -alignant lesions0 La/arosco/y has e1ol1ed as an in4or-ati1e, i-/ortant -ethod o4 diagnosing a 2ide s/ectru- o4 both benign and -alignant diseases0 ,lecti1e diagnostic la/arosco/y re4ers to the use o4 the /rocedure in chronic intra$abdo-inal disorders0 ,-ergency diagnostic la/arosco/y is /er4or-ed in /atients /resenting 2ith acute abdo-en0 The indications for diagnostic laparoscopy can be di ided into fo!r "ain gro!ps# $on%tra!"atic& non%gynaecological ac!te abdo"en li'e# o 9//endicitis o Di1erticulitis o Duodenal /er4oration o (esenteric adenitis0 o Intestinal adhesion
o =-ental necrosis0 o Intestinal in4arction0 o Co-/licated (ec>el?s di1erticulu-0 o @edside La/arosco/y in the ICA0 o 5orsion o4 intra$abdo-inal testis0 (ynaecological abdo"inal e"ergencies li'e# o =1arian cysts0 o Pel1ic in4la--atory diseases0 o 9cute sal/ingitis0 o ,cto/ic /regnancy0 o ,ndo-etriosis0 o Per4orated uterus due to cri-inal abortion o :al/ingitis Abdo"inal tra!"a# Ad antages# Diagnostic la/aroto-y 4or abo1e -entioned abdo-inal condition is /er4or-ed by general surgeon since long but la/arosco/ic diagnostic la/arosco/y has 4ollo2ing ad1antages: o Cos-etically better outco-e0 o Less tissue dissection and disru/tion o4 tissue /lanes o Less /ain /osto/erati1ely0 o Lo2 intra$o/erati1ely and /osto/erati1e co-/lications0 o ,arly return to 2or>0 o @etter 1isualiBation o4 Para$colic gutters and /el1ic ca1ity 2hich is not /ossible by diagnostic la/aroto-y OP)RATI*) T)CH$I+,) Patient Position o 5he /atient is /laced on the o/erating table 2ith the legs straight or lithoto-y /osition i4 4e-ale0 o 5he o/erating table is tilted head u/ or do2n by a//ro3i-ately 1' degree de/ends on the -ain area o4 e3a-ination0 o Co-/ression bandage -ay be used on leg during the thro-boe-bolis- es/ecially i4 /atient is in lithoto-y /osition0 o 5he surgeon stands on le4t side o4 the /atient0 o 5he 4irst assistant, 2hose -ain tas> is to /osition the 1ideo ca-era, is also on the /atient?s le4t side0 o 5he instru-ent trolley is /laced on the /atient?s le4t allo2ing the scrub nurse to assist 2ith /lacing the a//ro/riate instru-ents in the o/erating /orts0 o/eration to /re1ent
o 5ele1ision -onitors are /ositioned on either side o4 the to/ end o4 the o/erating table at a suitable height so surgeon, anesthetists, as 2ell as assistant can see the /rocedure0 Anaesthesia# Recently local anaesthesia "1C lidocaine# is 4a1ored by 4e2 surgeons0 <o2e1er, the -aDority uses general anaesthesia0 General endotracheal anaesthesia is used0 ,ach /atient is inDected in the /re$induction /hase 2ith *0-g I( Contra-ol, IE (etronidaBole or 5inidaBole and 2ith 2grs0 o4 Ce4iBo3 IE0 5he /ro/hylactic antibiotic is generally not indicated in diagnostic la/arosco/y but in tro/ical country li>e India it is ad1isable to use /ro/hylactic antibiotic Creation of Pne!"operitone!"Pneu-o/eritoneu-, on a1erage )$10--<g, is created using Eeress needle0 5rans$u-bilical insertion o4 the Eeress needle and o/tical /ort should be used0 9n e3trau-bilical /lace-ent -ay be used 2hene1er surgical /eri$u-bilical scars 2ere /resent or adhesions sus/ected0 o Chec> Eeress needle be4ore insertion0 o Chec> 1eress needle ti/ s/ring0 o Con4ir- that gas connection is 4unctioning0 o ,nsure 4lushing 2ith saline does not bloc> that needle0 o (a>e a s-all incision Dust abo1e the u-bilicus0 o Li4t u/ abdo-inal 2all and gently insert Eeress needle till a 4eeling o4 gi1ing 2ay0 o Con4ir- /osition o4 needle by saline dro/ -ethod0 o Connect C=2 tube to needle0 o :2itch o44 gas 2hen desired /neu-o/eritoneu- is created and re-o1e the Eeress needle 5he o/en techniFue 4or trocar insertion is reco--ended i4 /atient /resents 2ith se1ere abdo-inal distension0 Nitrous o3ide is used i4 diagnostic la/arosco/y is /er4or-ed in local anaesthesia because Nitrous o3ide has its o2n analgesic e44ect0 Carbon dio3ide is the /ro44ered gas i4 diagnostic la/arosco/y is /er4or-ed under general anaesthesia0 Insu44lation should be 1ery slo2 and 2ith care ta>en not to e3ceed 1200 --<g0 Port location#
(enerally one optical port in !"bilic!s and one ."" port in left iliac fossa are re/!ired
9 three$/ort a//roach should be used i4 there is any di44iculty in -ani/ulation0 o 10-- u-bilical "o/tical#, o ' -- su/ra/ubic and o ' -- right hy/ochondriu-0 9 &0G telesco/e is e-/loyed in -ost instances, as this 4acilitates easier ins/ection o4 the /eritoneal ca1ity and abdo-inal organs0 5he secondary /orts are inserted under la/arosco/ic 1ision0 5he selected site on the abdo-inal 2all is identi4ied by 4inger indentation o4 the /arietal /eritoneu-0 Inspection#
Start
Inspection of Pel is
Patient should again positioned in steep trendelenberg position The full length of fallopian tube %rom cornua to fimbriae The round ligament Anterior cul de sac $terus
Carcino"a li er
Hae"angio"a
Carcino"atosis
)ndo"etriosis
)ctopic pregnancy
0icorn!ate !ter!s
Polycystic o ary
1ibroid
Adhesion of Appendi2
Di ertic!l!"
I"palpable Testes
Perforation
o 9bdo-inal organs are ins/ected 4or any /athology o 9bdo-inal ca1ity is ins/ected 4or 4luids0 o :a-/les are ta>en i4 4ree 4luid is /resent 4or laboratory tests "che-istry, cytology or bacteriology#0 o Peritoneal la1age and adhesiolysis -ay need to be /er4or-ed to i-/ro1e 1isualisation o4 organs0 o 5hera/eutic la/arosco/y is then underta>en, i4 indicated and surgeon is e3/erienced enough0 )nding of the operationo ,3a-ine the abdo-en 4or any /ossible bo2el inDury or hae-orrhage0 o Re-o1e the Instru-ent and then /ort0 o Re-o1e telesco/e lea1ing gas 1al1e o4 u-bilical /ort o/en to let out all the gas0 o Close the 2ound 2ith :uture0 o Ase 1icryl 4or rectus and An$absorbable intra$der-al or :ta/ler 4or s>in0 o 9//ly adhesi1e sterile dressing o1er the 2ound0
5he usual site o4 insertion o4 the trocarHcannula 4or diagnostic la/arosco/y is belo2 or to the side o4 the u-bilicus0 5his /osition -ay reFuire to be altered in the /resence o4 abdo-inal scars0 5he use o4 a &0 degree 4or2ard obliFue telesco/e is /re4erable 4or 1ie2ing the sur4ace architecture o4 organs0 @y rotation o4 the telesco/e, di44erent angles o4 ins/ection can be achie1ed0 5he 4irst i-/ortant ste/ a4ter access to the abdo-en has been gained is to chec> 4or da-age caused by trocar insertion0 9 second ' -- /ort -ay then be inserted under 1ision in an a//ro/riate Fuadrant to ta>e a /al/ating rod0 9 syste-atic e3a-ination o4 the abdo-en -ust then be /er4or-ed Dust as in la/aroto-y0 Ie begin at the le4t lobe o4 the li1er but any sche-e can be used as long as it is consistent0 Ne3t, chec> around the 4alci4or- liga-ent to the right lobe o4 li1er, gallbladder and hiatus0 94ter chec>ing the sto-ach, -o1e on to the caecu- and a//endi3 and chec> the ter-inal ileu-0 Follo2 the colon round to the sig-oid colon, and then chec> the /el1is0 Jou should be con1ersant 2ith sa-/ling and bio/sy techniFues, and the use o4 /osition and -ani/ulation to aid 1ision0 5his is the 4irst /rocedure to be -astered 2hen learning la/arosco/ic surgery0 Ihen /er4or-ing a diagnostic la/arosco/y to con4ir- a//endicitis, a 4i1e -- /ort is /laced in the le4t iliac 4ossa to 4acilitate -ani/ulation0 5he /atient is /laced head do2n and rotated to the le4t to dis/lace the s-all bo2el 4ro- the /el1is and allo2 the uterus and o1aries to be chec>ed0 5his ho2e1er should be li-ited to a1oid conta-ination o4 sub/hrenic s/aces i4 this is not already /resent0 Patient -ay be discharged on the sa-e day a4ter o/eration i4 e1ery thing goes 2ell0 5he /atient -ay ha1e slight /ain initially but usually resol1es0 Diagnostic la/arosco/ic is a use4ul -ethod 4or reducing hos/ital stay, co-/lications and return to nor-al acti1ity i4 carried on in /ro/er -anner0 Iith better training in -ini-al access surgery and better ergono-ics no2 a1ailable the ti-e has arri1ed 4or it to ta>e its /lace in the surgeon?s re/ertoire0
For More Information Contact: Laparoscop& Hospital $nit of Shanti Hospital' ()*+ Tila" ,agar' ,ew -hone. /0*1+2**3 45*554+4 /0*1+20(**6*7(8(' 0(**0*497( :mail. contact;laparoscop&hospital.com elhi' **++*(. #ndia.