General Surgeon In Pune - Laparoscopy Surgeon In Pune

1
History

• 1902 - Georg Kelling, of Dresden, Saxony,
  performed the first laparoscopic procedure on
  dogs.
• 1910 - Hans Christian Jacobaeus of Sweden,
  reported the first laparoscopic operation on
  humans.
• 1980 - Patrick Steptoe from England, started to
  perform laparoscopic procedures in the operating
  room under sterile conditions.
• 1982 - The first solid state camera was
  introduced and this was the start of
  'video-laparoscopy'.
• 1987 - Phillipe Mouret performed the first
  video-laparoscopic cholecystectomy in Lyons,
  France.
• 1994 - A robotic arm was designed to hold the
  laparoscope camera and instruments.
• 1996 - The first ever live broadcast of
  laparoscopic surgery via the Internet was
  performed.
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2
What is Laparoscopic Surgery?

• Laparoscopic surgery, also known as minimally
  invasive surgery (MIS) or keyhole surgery is a
  modern surgical technique for carrying out
  operations in the abdomen through cannulae (also
  known as ports) which are channels into the body
  through small incisions.
•  
• Using a video camera the surgeon is able to view
  the operative field without invasive surgery. The
  abdomen is usually insufflated with carbon
  dioxide gas.
• By inflating the abdomen, the abdominal wall is
  elevated above the internal organs to create a
  working and viewing space for the surgeons.
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3
Why Laparoscopy?

• There are a number of advantages to operating on
  the patient with laparoscopic surgery versus open
  surgery. Some of these are
•  
• Less post-operative scarring
• Reduced pain
• Shorter recovery time
• Less time spent in hospital to recover
• Reduced hemorrhaging
• Reduced risk of exposing internal organs to
  external contaminants
• Quicker return to normal activities
• Quicker return to work

4

• The Rise of Bariatric Surgery
• One of the most common types of laparoscopic
  surgery is bariatric (obesity). Over the last
  decade there have been more advancements in
  bariatric surgery than there had been in the
  previous 50 years, fuelled largely by the growing
  obesity epidemic which began in the 1970s. The
  epidemic created the need for effective treatment
  of severe obesity and its co morbidities leading
  to the development of procedures such as gastric
  banding, gastric bypass and duodenal switch over
  the past decade. More recently, the advent of
  minimally invasive surgery in the mid-1990s
  accounted for the second wave of advances.
• Before Laparoscopic Surgery
• Before laparoscopy was practiced, surgeons
  operated using open/invasive surgery. This means
  cutting skin and tissues so that the surgeon has
  direct access to structures and organs. This
  involves more direct access than in minimally
  invasive procedures as the openings are bigger so
  the internal organs are openly exposed.
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5
Laparoscopic Surgery

• Cholecystectomy, Appendectomy Colectomy
• Vagotomy
• Hiatal, Inguinal Diaphragmatic hernia
  repair
• Urological- Nephrectomy, Adrenelectomy
  Prostatectomy.
• OBG-Tubal surgeries,cystectomies,hystrectomie
  s various ablations (endometriosis)
• Thoracoscopies
• Neurosurgeries
• Lumbar discectomies
• Diagnostic procedures
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6
Advantages and Disadvantages

• Advantages
• Minimal pain illeus
• Improved cosmesis
• Shorter hospital stay , faster recovery rapid
  return to work
• Non muscle splinting incision less blood loss
• Post op respiratory muscle function returns to
  normal more quickly
• Wound complications i.e. infection dehiscence
  are less
• Lap surgery can be done as day care surgery
•  
• Disadvantages
• Longer duration of surgery
• Loss of 3D view, impaired touch sensation
• poor dexterity, fulcrum effect, risk of visceral
  / vsl. Injury (may go unrecognised)
• Long learning curve for surgeons
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7
Fig. Demonstarting surgical incision Sites in lap
cholecystectomy
8
INSUFFLATING GAS OF CHOICE FOR LAPROSCOPY

• Ideal insufflating gas of choice
• Colorless, non toxic, nonflammable, easily
  available, inexpensive, inert, readily soluble in
  blood and easily ventilated out of lungs
• Why CO2 is the gas of choice for laparoscopy?
• Nonflammable does not support combustion
• Highly soluble in blood because of rapid
  buffering in blood so risk of embolisation is
  small
• Rapidly diffusible through membranes so
  easily removed by lungs
• CO2 levels in blood expired air can be
  easily measured its elimination is augmented by
  increasing ventilation
• CO2 is readily available is inexpensive
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9
PROPERTIES OF OTHER GASES USED
Gas Oswalds BG solubility coef. complications
Air 0.017 Supports combustion, Gas embolism
Oxygen 0.036 do
Nitrogen Gas embolism
N2O 0.042 Supports combustion (if mixed with methane from bowel), Bowel distension, PONV, Explosion with cautery
CO2 0.49 Hypercarbia, Pain abdomen ,Shoulder tip pain, Arrythmia, Promotion of port site tumour growth, peritoneal irritant
He 0.00098 Embolism, diffusible, expensive
Argon Embolism, expensive

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10
PHYSIOLOGICAL CHANGES

• Physiologic effects seen with CO2 insufflations
  are transient and derive from the body's reaction
  to increases in intra abdominal pressure and CO2
  absorption as it tries to achieve a new state of
  homeostasis. People who are otherwise healthy
  will tolerate laparoscopy well, while individuals
  with underlying cardiopulmonary or renal diseases
  may not tolerate prolonged CO2 insufflations.
  Additionally, patient positioning, for example
  steep Trendelenburg in prostatectomy, can
  exacerbate cardiovascular alterations in
  laparoscopy.
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11
CARDIOVASCULAR RESPONSE

• Cardiovascular changes vary with intra abdominal
  pressure, with higher pressures associated with
  more significant changes than lower pressures. In
  any other case healthy patients undergoing
  laparoscopy, the threshold intra abdominal
  pressure that led to hemodynamic changes was 12
  mm Hg. Those with underlying cardiac disease will
  likely have a lower intra abdominal pressure
  threshold.
• Heart rate may rise transiently in response to
  increases in SVR and arterial blood pressure
  level to maintain cardiac output, but most
  studies have reported no significant long-term
  changes in heartbeat with laparoscopy. In a tiny
  subset (0.5) of otherwise healthy patients,
  however, bradycardia and asystole can occur
  during CO2 insufflation and pneumoperitoneum.
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12
RESPIRATORY RESPONSE

• CO2 may be the gas of choice for laparoscopic
  surgeries because it is noncombustible, extremely
  soluble, and readily eliminated with the lungs.
• Despite the proven effectiveness and protection
  of CO2 for insufflation in laparoscopy, the
  respiratory response to mechanical improves in
  intra abdominal pressure as well as hypercapnia
  from absorption should be considered.
• With CO2 insufflation and increases in intra
  abdominal pressure, the dintra abdominal
  pressurehragm is pushed cephalad into the
  thoracic cavity, constraining downward dintra
  abdominal pressurehragmatic excursion with
  respiration. All round functional respiratory
  capacity, vital capacity, and pulmonary
  compliance drop with boosts in intra abdominal
  pressure, and peak airway and plateau pressures
  can enhance up to 50 and 81, respectively.
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13
RENAL RESPONSE

• Mechanistically, as intra abdominal pressure
  increases, its compressive effects on the renal
  vasculature, the renal parenchyma, and the IVC
  will reduce effective renal blood circulation
  (ERBF), cortical and medullary perfusion, and
  renal venous outflow.
• The renal effects are mild to negligible once the
  intra abdominal pressure is under 10 mm Hg, but
  as intra abdominal pressure reaches and exceeds
  15 mm Hg, there's a pressure-dependent decrease
  in the glomerular filtration rate (GFR), ERBF,
  creatinine clearance, sodium excretion, and
  urinary output. In a typical intra abdominal
  pressure of 15 mm Hg, urinary output decreases by
  as much as 63 to 64, GFR by 21, and ERBF by
  26. Despite this drop, however, there are no
  long-term renal squeal, even in patients with
  pre-existing renal disease, and
  pneumoperitoneum-induced renal failure does not
  occur.
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14
METABOLIC RESPONSE

• Metabolic acidosis from CO2 absorption is the
  primary derangement with laparoscopy. Systemic
  CO2 absorption and resultant metabolic
  consequences differ depending on the patient's
  underlying respiratory status since the lung
  eliminates absorbed CO2 buffered by the blood. In
  otherwise healthy patients, an increase in minute
  ventilation is enough, but for individuals with
  COPD, removal of CO2 is less capable, causing
  them to are afflicted by more major and extended
  derangements in acid-base balance. As stated
  earlier, desufflation might be necessary during a
  long laparoscopic procedure in patients with COPD
  or interstitial lung condition.
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15
Causes for Paco2 during Laparoscopy

•  
• Absorption of carbon dioxide (CO2) from the
  peritoneal cavity
• VA/Q mismatch
• Increased physiologic dead space
• Abdominal Distention
• Position of the patient (e.g., steep tilt)
• Controlled mechanical ventilation
• Reduced cardiac output
• These mechanisms are accentuated in sick patients
• Increased metabolism (e.g., insufficient plane of
  anesthesia)
• Depression of ventilation by anesthetics (e.g.,
  spontaneous breathing)
• Accidental events
• CO2 emphysema (i.e., subcutaneous or body
  cavities)
• Capnothorax
• CO2 embolism (Selective bronchial intubation)

16
ANAESTHESIA

• PAC
• Done in usual manner with special attention to
  cardiac pulmonary system
•  
• Investigations
• Complete hemogram
• RBS
• Na, K
• BUN, Creatinine
• Coagulation profile
• CXR, ECG
• BG, CM
•  
• Special investigations
• ECHO
• PFT
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17
PREMEDICATION

• NPO
• Complete bowel preparation
• Antibiotics as per surgical team
• Awareness about post op shoulder tip pain
• Written informed consent for laparotomy
• Anxiolytics/antiemetics/H2 receptor
  antagonist/analgesic
• Antisialagogue (glyco-P) and vagolytic may be
  administered at induction of anaes.
• DVT prophylaxis (rTn, pelvic Sx, long
  duration, malignancy, obesity)
• Clonidine/ dexmetetomidine to decrease stress
  response
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18
MONITORING

• HR
• NIBP
• Continous ECG
• Pulse oximetry
• Capnography
• Temperature
• Airway pressure
• IAP
• If required, ABG, precordial doppler,TEE may
  be instituted.
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19
CO2 s/c emphysema

• Cause
• accidental extraperit insufflation
  (malpositioned verris needle)
• deliberate extraperit insufflations-
  retroperit surg,TEPP,fundoplication, pelvic
  lymphadenectomy
• Diagnosis
•  
• ETCO2 -cannot be corrected by adjusting
  ventilation even after plateau reached
• ABG, Palpation
• Treatment
• Stop CO2 insufflation, interrupt lap
  temporarily
• CMV continued till hypercapnia resolves
• Resume lap at low insufflation P thereafter
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20
Pneumothorax / pneumomediastinum

• Cause
• pleuroperitoneal communications (RgtL)
• Diaph defects( aortic, esophageal, GE jn surg)
• Rupture of preexisting bullae
• Perf falciform ligament
•  
• Diagnosis
• airway P, sudden ?Sp O2 , sudden ?/ ? ETco2,
• Abnormal motion of hemidiaph by laparoscopist
• PNEUMOTHORAX

CAPNOTHORAX ? ET CO2 (may fall later) ? V CO2, ? PaCO2, AIR PNEUMOTHORAX ?ET CO2 (due to ?CO)
Stop N2O 100 O2 IAP PEEP Thoracocentesis not needed Inform surgeon Do not apply PEEP Mandatory
21
CO2 embolism (rare but potentially fatal)

• Risk factors
• hysteroscopies, previous abd surg, needle/Trocar
  in vsl
• Consequences-
• GAS LOCK in vena cava ,RA ? ? VR ? collapse -
  Ac RV HTN ? opens foramen ovale ? paradoxical gas
  embolism
•  
• Diagnosis
• HR, ?BP, ? CVP, hypoxia, cyanosis, ET CO2
  biphasic change, ?a ETco2 ECG- Rt heart strain,
  TEE, pulm art. Aspiration of gas/ foamy bld from
  CVP line
• Treatment
• Release source (stop co2 release pneumoperit)
• position steep head low durant position
• stop N2O 100O2
• Hyperventilation
• CVP/PA catheter to aspirate CO2
• Cardiac massage may break embolus- rapid
  absorption
• Hyperbaric o2 - cerebral embolism
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22
Endobronchial intubation

• Due to cephalad movement of diaph with head
  down tilt and ? IAP
• Diagnosis - Sp O2 ? airway P
•  
• Treatment Repositioning of ETT
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23
Aspiration

• Mendelson syndrome
• At IAPgt20 mmHg
•  
• Changes in LES due to IAP that maintain
  transsphincteric P gradient head down position
  protect against entry of gastric content in
  airways
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24
Nerve injuries

• Prevented by
• avoid overextension of arms
• padding at P points
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25
Laparoscopy in children 

• Physiological changes adults
• Paco2 ETco2 increase but ETco2 overestimates
  Paco2
• Co2 abs more rapid and intense due to larger
  peritoneal SA / body wt.
• More chances of trauma to liver during trocar
  insertion
• More chances of bradycardia , maintain IAP to as
  low as possible
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•  

26
Laparoscopy in pregnancy

•  
• Indications-
• appendicectomy
• cholecystectomy
•  
• Risk preterm labour, miscarriage, fetal
  acidosis
• Timing II trimester (lt 23 wk)
• Lap technique HASSANS tech
• Special considerations
• prophylactic- antithrombolytic measures
  tocolytics
• operating time to be minimised
• IAP as low as possible
• Continous fetal monitoring (TVS)
• Lead shield to protect foetus if intraop
  cholangiography needed
•  
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