Introduction to Minimally Access Surgery

DR. SHAHZAD ALAM SHAH

CONSULTANT LAPAROSCOPIC SURGEON FATIMA JINNAH MEDICAL COLLEGE/ SIR GANGA RAM HOSPITAL LAHORE

Introduction
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Minimal
a

Access surgery :

marriage of modern technology and surgical innovation that aims to accomplish surgical therapeutic goals with minimal somatic and psychological trauma.

Broadly speaking, minimal access techniques can be categorized as follows: 1. Laparoscopy 2. Thoracoscopy 3. Endoluminal endoscopy 4. Periviseral endoscopy 5. Arthroscopy and intra-articular joint surgery 6. Combined approach

Historical Landmarks of Laparoscopic Instruments

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1901 First Cystoscopy German surgeon Georg Kelling performed first experimental laparoscopy in Berlin

1911 Trocar Was Introduced H.C. Jacobaeus of Stockholm coined the term "laparothorakoskopie" after using this procedure on the thorax and abdomen 1929 Lens System Developed Heinz Kalk, a German gastroenterologist developed a 135 degree lens system and a dual trocar approach.

Historical Landmarks of Laparoscopic Instruments

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1953 Telescope With Rod Lens System

The rigid rod lens system was discovered by Professor Hopkins. The credit of videoscopic surgery goes to this surgeon who has revolutionized the concept of endoscopic surgery.

1960 Automatic Insufflator

Kurt Semm, a German gynecologist, who invented the automatic Insufflator capable of monitoring intra-abdominal pressures.

1987 Video Technique Used

Phillipe Mouret, has got the credit to perform the first laparoscopic cholecystectomy in Lyons, France using video technique.

1994 Robbotic Arm Used For Laparoscopy A robotic arm was designed to hold the telescope with the goal of improving safety and reducing the need of skilled camera operator. 1996 First Robotic Telesurgery

First live telecast of laparoscopic surgery performed remotely via the Internet. (Robotic Telesurgery)

Advantages
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Reduced Postoperative pain Wound Complication Accelerated recovery Good cosmetic results Incidence of abdominal adhesions and postoperative

ileus Early return to work Cost?

Advantages
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Reduced contact with patients body fluids

More Safe?

Limitations of Laparoscopy
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Loss of tactile sensations (haptics)

Reduced hand eye coordinations

Two dimentional image Reduced depth perception

Ergonomically difficult
Expensive Instrumentation (disposables) Haemostasis may be more difficult

Organ retrieval difficulties

Contraindications and Risk Factors

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Contraindications are same as in open surgery

Risk Factors Co-morbid Factors Coagulopathy Previous surgeryadhesions Abdominal Wall Pathology

Difficulties of Laparoscopic Surgery

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Requires more technical expertise

Long operative time

Learning curve

Instrumentations in Laparoscopic Surgery

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Laparoscopic Trolly
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The Optical Chain Endoscope Light Cable Light Source Camera System Monitor Gas Insufflation Apparatus Insufflator Carbon Dioxide Cylinder

Light Cable
Fiber Optic cable

Liquid crystal Gel cable

Instrumentations in Laparoscopy
Fiber Optic cable 1954
Bundles of fibers Multiple total internal reflection of light High quality of optical transmission Flexibility

Instrumentations in Laparoscopy
The Light Source The quality of the image depends upon the quantity of light available at each step of the system
A typical light source is consist of

A lamp A heat filter A condensing lens and Manual or automatic intensity control circuit

The Light Source

The Lamp Halogen Halogen Halide Xenon Most Frequently used two main lamps are halogen

and xenon

 Why xenon light source is better? Light emitted is more natural Cold light More intense > more than 300 Watts Heat Filters are used White balancing is important

Laparoscope/Endoscope
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Structure of Endoscopes

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Parts of Endoscopes

Laparoscopes/Endoscopes
Function of Endoscopes Focal Length Brightness Depth of Field Periphery Light Loss (vignette)

Laparoscopes/Endoscopes
Choice of Endoscopes Direction (angle) of View Caliber of Endoscopes

Video Camera
The Camera Head

Camera Control Unit

 Types of Cameras Single Chip Three Chip High Definition Cameras

Monitors
CRT Monitors (Medical Grade)

LCD

High Definition (Medical Grade Monitors)

Working Instruments
Hand Instrumants Disposables Reusables

Hand Instruments
Handle

Outer Sheath

Inserts

Hand Instruments
Structure and function

Diameter Length Freedom of movements

Basic Laparoscopic Instruments

Veress needle

Trocars
Forceps Graspers

Hook
Pair of Scissors Suction irrigation system

Clip Applier/Clips
Needle Holder

Abdominal Access Techniques/Creation of Pneumoperitoneum

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DR. SHAHZAD ALAM SHAH

ASSIST. PROF. OF LAPAROSCOPIC SURGERY FATIMA JINNAH MEDICAL COLLEGE/ SIR GANGA RAM HOSPITAL LAHORE

Access Techniques
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In Laparoscopic Surgery the first entry into the abdomen with telescope and Instruments is called Access technique.

Port Positions in Laparoscopic Procedures

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Laparoscopic Cholecystectomy

Port Positions
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Laparoscopic Appendicectomy

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open access hassan technique laparoscopy

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Lahore Laparoscopic Surgery Training Center MIDCITY HOSPITAL LAHORE PAKISTAN

Access Techniques
Two Types

Open Technique Closed Technique

Access Techniques
Closed Technique Closed Technique is the safe Access Technique

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Creation of Pneumoperitoneum
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Insufflators are necessary for

The creation of the pneumoperitoneum Its maintenance during the procedure Control of the gas pressure with in the abdomen Periodical renewal of pneumoperitoneum

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Veress Needle Technique or Closed Method

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Lahore Laparoscopic Surgery Training Center MIDCITY HOSPITAL LAHORE PAKISTAN

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Lahore Laparoscopic Surgery Training Center MIDCITY HOSPITAL LAHORE PAKISTAN

Insufflation and Insuflators

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