History of Laparoscopy

History of Laparoscopy 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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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.



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

Reduced wound complicationshttp://www.drsanjaykolte.in/


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.



Laparoscopic Surgery Cholecystectomy, Appendectomy & Colectomy

Vagotomy

Hiatal, Inguinal & Diaphragmatic hernia repair

Urological- Nephrectomy, Adrenelectomy & Prostatectomy.

OBG-Tubal surgeries,cystectomies,hystrectomies & various ablations (endometriosis)

Thoracoscopies

Neurosurgeries

Lumbar discectomies

Diagnostic procedureshttp://www.drsanjaykolte.in/


Advantages and DisadvantagesAdvantagesMinimal pain & illeusImproved cosmesisShorter hospital stay , faster recovery & rapid return to workNon muscle splinting incision & less blood lossPost op respiratory muscle function returns to normal more quicklyWound complications i.e. infection & dehiscence are lessLap surgery can be done as day care surgery

DisadvantagesLonger duration of surgeryLoss of 3D view, impaired touch sensationpoor dexterity, fulcrum effect, risk of visceral / vsl. Injury (may go unrecognised)Long learning curve for surgeons



Fig. Demonstarting surgical incision Sites in lap cholecystectomy



INSUFFLATING GAS OF CHOICE FOR LAPROSCOPY

Ideal insufflating gas of choiceColorless, 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



PROPERTIES OF OTHER GASES USED


Gas Oswalds B:G 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


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.



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.



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.



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.



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.



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)



ANAESTHESIA

PACDone 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



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



MONITORING

HR

NIBP

Continous ECG

Pulse oximetry

Capnography

Temperature

Airway pressure

IAP

If required, ABG, precordial doppler,TEE may be instituted.



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



Pneumothorax / pneumomediastinumCause pleuroperitoneal communications (R>L)Diaph defects( aortic, esophageal, GE jn surg)Rupture of preexisting bullaePerf 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 % O2IAPPEEPThoracocentesis not neededInform surgeon

Do not apply PEEPMandatory


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 DiagnosisHR, ↓BP, CVP, hypoxia, cyanosis, ET CO2 biphasic change, Δa ETco2 ECG- Rt heart strain, TEE, pulm art. Aspiration of gas/ foamy bld from CVP line

TreatmentRelease source (stop co2 + release pneumoperit)position – steep head low + durant position stop N2O + 100%O2HyperventilationCVP/PA catheter to aspirate CO2Cardiac massage may break embolus- rapid absorptionHyperbaric o2 - cerebral embolism



Endobronchial intubation

Due to cephalad movement of diaph with head down tilt and IAP

Diagnosis - Sp O2 ↓ airway P

Treatment – Repositioning of ETT



Aspiration

Mendelson syndromeAt IAP>20 mmHg

Changes in LES due to IAP that maintain transsphincteric P gradient + head down position protect against entry of gastric content in airways



Nerve injuries

Prevented byavoid overextension of arms

padding at P points



Laparoscopy in children

Physiological changes = adultsPaco2 ETco2 increase but ETco2 overestimates Paco2Co2 abs more rapid and intense due to larger peritoneal SA / body wt.More chances of trauma to liver during trocar insertionMore chances of bradycardia , maintain IAP to as low as possible



Laparoscopy in pregnancy

Indications- appendicectomycholecystectomy Risk – preterm labour, miscarriage, fetal acidosisTiming – II trimester (< 23 wk)Lap technique – HASSANS techSpecial considerations prophylactic- antithrombolytic measures + tocolyticsoperating time to be minimisedIAP as low as possibleContinous fetal monitoring (TVS)Lead shield to protect foetus if intraop cholangiography needed



About Dr. Sanjay KolteDNB, FMAS(AMASI IDIA), F.C.P.S.(Mumbai)

MBBS - OCTOBER 1995-BHARATI VIDYAPEETH'S MEDICAL COLLEGE, PUNE, INDIAFCPS (General Surgery) - SEPTEMBER 2000, MUMBAI, INDIA

(FELLOW OF COLLEGE OF PHYSICIANS AND SURGEONS)

DNB (General Surgery) - MAY 2001-KING EDWARD MEMORIAL HOSPITAL, PUNE, INDIA (DIPLOMATE OF NATIONAL BOARD, NEW DELHI)MNAMS - MEMBER OF NATIONAL ACADEMY OF MEDICAL SCIENCES, NEW DELHI

Contact Details:Laparoscopic Surgery Clinic, Parihar Chowk, Aundh, Pune, Maharashtra 411007Mobile : 91+98 22 00 94 90Email : [email protected]

http://www.drsanjaykolte.in


History of Laparoscopy

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