This presentation will help u know with the history,present and coming up trends in laparoscopy .Also it is an acquaintance presentation regarding laparoscopy.

1. Presented by:-
Dr.Mohsin Khan
PG Resident
MS (General Surgery)
GRMC Gwalior
Guide:-
Dr.Amit Ojha
MS
Asst.Prof.
Deptt of Surgery
GRMC Gwalior

2. The first description dates ttoo HHiippppooccrraatteess iinn
GGrreeeeccee,, ffoorr uussee ooff aa ssppeeccuulluumm ttoo vviissuuaalliizzee
tthhee rreeccttuumm ((446600––337755 BBCC))..
A three bladed speculum was found in the ruins
of Pompeii*.
*A roman town buried by a volcano eruption
near modern Naples, Italy - 79 AD).

3.  1910: Swedish internist; first
thoracoscopic diagnosis with a
cystoscope in a human subject.
 Treatment of a patient with tubercular
intra-thoracic adhesions.
The Possibilities for PPeerrffoorrmmiinngg CCyyssttoossccooppyy iinn
EExxaammiinnaattiioonnss ooff SSeerroouuss CCaavviittiieess.. MMüünncchhnneerr MMeeddiizziinniisscchheenn
WWoocchheennsscchhrriifftt,, 11991111

4.  1911 : First laparoscopy at Johns Hopkins
 12mm proctoscope into epigastric incision
on one of Halstead’s patients to stage
pancreatic cancer
 Bernheim called his procedure
‘organoscopy’
 Findings confirmed on laparotomy

5.  1920: Zollikofer discovered the benefit of CO2 gas for insufflation
 1938: Janos Veress developed a spring loaded needle for the
induction of pneumoperitoneum.
 After World War II, the development of fiberoptics represented an
important step forward for endoscopy
 1966: Hopkins rod lens scope & cold light
 1974: Dr Harrith M Hasson, MD working in Chicago, proposed a
blunt mini-laparotomy which permitted direct visualization of the
trocar entrance into the peritoneal cavity. It is popularly known
today as Hasson‘s technique.

6.  1985: Dr. Muhe (Prof Dr Med - Böblingen, Germany)
performed the first successful laparoscopic
cholecystectomy in a human. However, this was not
well publicized until years later. The German Surgical
Society rejected Mühe in 1986 after he reported that he
had performed the first laparoscopic cholecystectomy.

7.  Minimal access surgery is a marriage
of modern technology and surgical
innovation that aims to accomplish
surgical therapeutic goals with
minimal somatic and psychological
trauma

8.  Laparoscopy
 Thoracoscopy
 Endoluminal endoscopy
 Arthroscopy and intra-articular joint
surgery
 Combined approach

9. DIAGNOSIS
Gallstone
Appendicitis
Hernia
Adhesions
Perforated ulcer
Hiatus Hernia
OPERATION
Cholecystectomy
Appendicectomy
Hernia repair
Division of adhesions
Closure of
perforation
Hiatus hernia repair.

10. DIAGNOSIS
Colorectal
carcinoma
Caecal carcinoma
Colonic carcinoma
Gastric carcinoma
Oesophageal
carcinoma
OPERATION
Anterior resection/ APR
Right Hemicolectomy
Left/Sigmoid Colectomy
Gastrectomy
Oesophagogastrectomy

11. Diagnosis
Crohn’s Disease
Diverticulitis
Rectal Prolapse
Benign renal disease
Gastric Obstruction
Some Splenic
disorders
The list is endless!!!
Operation
Bowel resection
Bowel resection
Repair of Prolapse
Nephrectomy
Bypass
Spleenectomy

12. FOR THE PATIENT
 Post operative pain related to size of
incision- smaller incisions =less pain.
 Less Handling of intestines results in little
or no disturbance of normal function.
 Avoidance of the trauma of abdominal
wall injury by the incision allows rapid
return to normal activity
 No incision allows early return to more
strenuous activities: driving, lifting, sport
etc.

13. FOR THE HOSPITAL
 Initial capital costs to establish laparoscopic
surgery in the order of Rs 10 - 20 lacs
 Reduced overall costs by shortening of
hospital stay e.g. cholecystectomy reduced
from 5 to 1 day, hiatus hernia repair reduced
from 7 to 3 days.

14. Open Surgeon
 Fast
 Hand is as good as eyes
 Dissection precedes
 Ergonomics: Optional
Laparoscopic Surgeon
 Slow and steady
 Stop when you don’t see
 Haemostasis precedes
 Ergonomics: Vital

15. For the Surgeon
 Magnified view often better than obtained
via an incision allows precise dissection.
 Altered (but not absent) tactile response
 Two dimensional (flat screen) view.
 Usually (but not always) longer operating
time
 Need to develop entirely different
operating technique
 Adaptation of principles of open surgery
to laparoscopic surgery.

16.  Redesign of instruments for laparoscopic use.
 Instruments for open surgery in general 6 –
10” in length built around a box joint.
 Laparoscopic instruments in general 15 – 18”
in length with an articulated connecting rod
between handles and scissor blades, jaws
etc.

17. Camera
Light Source
Insufflator
TV Monitor
Telescopes
Light Guide Cable
Apart from the
insufflator the
system will work
better if all the
components are
from the same
company as one
piece talks to
another

18.  These can be single chip
or 3 chip(red,green,blue).
 CHIP: this is also called a
charged coupled device
in short, CCD.
 These are flat silicone
wafers with a matrix, a
grid of minute image
sensors called pixels.
 White balance and
sometimes black balance

19.  Halogen or Xenon, cold
light.
 Brightest to darkest
measured in units of
decibels.
 White balance by making
sure white is correct then all
the colours through the
spectrum are correct.

20.  CO2 is used because this has the
same refractive index as air, so
doesn’t distort the image and is non
combustible.
 Intraabdominal pressure run
between 10 and 13 mmhg.
 Use disposable filter and tubing for
each patient.
 High flow insufflators (35 litres)
output determined by size of outlet.
 Ensure you know how to change a
cylinder and were they are stored.

21.  Usually a 20” screen.
 HD is better.
 You can use a standard TV
but it must be run through
an isolated transformer.
 Horizontal resolution is the
number of vertical lines.
 Vertical resolution is the
number of horizontal lines
 More lines of resolution,
better detail of picture.

22.  Different diameters
 Fibre light cable
 Autoclavable
 Don’t bend to acute angle as will
break fibres.
 Check when you plug them in are
all the fibres are okay.
 Condensers

23.  Single use
 Reusable
 Need an ultrasonic washer to effectively
clean them, not for telescopes.
 Don’t put 5mm cannulated instruments into
a bench top autoclave that does not have
a vacuum: vacuum is required to remove
all air form lumen of instrument.
 Ports 5 and 10mm are the most common,
make sure the right trocar is in port and is
it sharp.

24.  1938 - Janos Veress, of Hungary, developed
the spring-loaded needle. to perform
therapeutic pneumothorax (TB).
 Made of surgical stainless steel with a single
trap valve. 2mm diameter x 80mm length
 It consists of an outer cannula with a bevelled
needle point for cutting through tissues.

25. AABBDDOOMMIINNAALL AACCCCEESSSS IINNSSTTRRUUMMEENNTTSS
Open Technique Closed Technique
Hasson Cannula Veress Needle
Trocar Sheath
assemblies

26.  Controlled pressure insufflation ooff tthhee ppeerriittoonneeaall
ccaavviittyy iiss uusseedd ttoo aacchhiieevvee tthhee nneecceessssaarryy wwoorrkk
ssppaaccee ffoorr llaappaarroossccooppiicc ssuurrggeerryy..
 AAuuttoommaattiicc iinnssuuffffllaattoorrss aallllooww tthhee ssuurrggeeoonn ttoo
pprreesseett tthhee iinnssuuffffllaattiinngg pprreessssuurree,, aanndd tthhee ddeevviiccee
ssuupppplliieess ggaass uunnttiill tthhee rreeqquuiirreedd iinnttrraa--aabbddoommiinnaall
pprreessssuurree iiss rreeaacchheedd..

27. tro-car -
[Fr., troisis, three +carre, side]
noun
a sharp-pointed surgical instrument
fitted with a cannula and used
especially to insert the cannula into
a body cavity
cannula - [L., dim of
canna,reed] noun
a tube that is inserted into a cavity
by means of a trocar filling it’s lumen

28.  The trocar has a blade
with a shaft and body.
 The body includes a
pointed tip which makes
the initial incision in the
abdominal wall of the
patient.
(Trocar diameters range
from 2mm-30 mm)

29.  Types:
Cutting
 Pyramidal tipped
 Flat blade
Noncutting
 Pointed conical
 Blunt conical
 Optical

30.  Come in varying sizes, laparoscopes usually
5mm or 10mm.
 Diagnostic 3mm scope available.
 Made up of a rod and lens system.
 Bundles of fibres, incoherent carry light and
coherent carry image.
 Wide range of angles available 0, 30, 45 degree
are fairly standard.
 All laparoscopes are autoclavable and can go
through sterilisation, no ultrasonic bath
required.
 Endo- chameleon- extra long for Bariatric
patients.

31.  There are three important
structural differences in
telescope available
1. 6 to 18 rod lens system
telescopes are available
2. 0 to 120 degree telescopes
are available
3. 1.5 mm to 15 mm of
telescopes are available

32.  These cables are
made up of a bundle
of optical fibers glass
thread swaged at
both ends.
 The fiber size used is
usually between 10 to
25 mm in diameter.
 They have a very
high quality of optical
transmission, but are
fragile.

33.  Atraumatic
 KELLY atraumatic
 Atraumatic, with hollow jaws
 MANGESHKAR Grasping
Forceps, serrated

34.  Reusable three-piece design
 Available in 2 mm, 3 mm,
3.5mm, 5 mm and 10 mm
sizes, with lengths of 20 cm,
30 cm, 36 cm and 43 cm.
 Choice of handle styles.
 Fully rotating 360° sheath.
 No hidden spaces that can
trap operative blood and
tissue debris.

35.  HOOK SCISSORS, ssiinnggllee aaccttiioonn
jjaawwss
 MMEETTZZEENNBBAAUUMM SSCCIISSSSOORRSS,,
ccuurrvveedd,, lleennggtthh ooff bbllaaddeess 1122--1177 mmmm,,
wwiiddeellyy uusseedd aass aann iinnssttrruummeenntt ffoorr
mmeecchhaanniiccaall ddiisssseeccttiioonn iinn
llaappaarroossccooppiicc ssuurrggeerryy..
 SSTTRRAAIIGGHHTT SSCCIISSSSOORR ccaann ggiivvee
ccoonnttrroolllleedd ddeepptthh ooff ccuuttttiinngg bbeeccaauussee
iitt hhaass oonnllyy oonnee mmoovviinngg jjaaww..

36. Thoracic triangle
1 2
4 3
Pelvic triangle

37. Each quadrant must be
addressed from frontal
as well as lateral
positions.
y
z
x

39. “Dueling swords”
phenomenon
(scissoring effect)
Working against the
camera and ‘blind
spots’

40. To avoid
iatrogenic
injuries.

41. Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann
Surg 2004; 239:182

42. Incision line/trocar sites vs. nerve distribution
Iliohypogastric
n.
Ilioinguinal
n.
Epigastric a.
Trocar site Pfannenstiel
incision
(adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and
low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and
Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.)

44.  Straight Line
principle
 Triangulation
 Manipulation angle
 Elevation angle
 Low lying table
 Gaze down view

45. Surgeon
Pathology
Monitor

48. Monitor
S
C
R
L
P

49. Azimuth Angle;
Angle b/n scope and working hands
Manipulation Angle;
angle b/n working hands
30-45 degree
60-90 degree

51. 1. Manipulatation angle: 60 degree
2. Azimuth angle: Equal/30 degree each
3. Elevation angle: 60 degree

52. Ideal relaxed stature Tiring

53. -straight head, in the axis of the trunk,
without rotation or extension of the cervical spine;
- shoulders in a relaxed and neutral position;
- arms alongside the body
- elbows bent to 70 to 90 degrees
- forearms in an horizontal or slightly descending axis-
-hands pronated (physiological resting position);
- hands and fingers lightly grip the handles/handpiece
•Waist line table
•Gaze down view of monitor
•Straight line principle
•Triangulation

54. Trocar distance from
the
target organ depends
upon
the size of the patient.
Individual trocars can be
moved closer to the
target along an axis line.
Additional
trocars can be
added along
the
semicircular
line.

55. CCOOMMPPLLIICCAATTIIOONNSS OOFF
LLAAPPAARROOSSCCOOPPIICC SSUURRGGEERRIIEESS
1. Anaesthetics Complications
2. Complications due to pneumoperitonium
3. Surgical complications
4. Diathermy related injuries
5. Patients factors related complications
6. Post operative complications

56. CCOOMMPPLLIICCAATTIIOONNSS
Anaesthetic Complications :
1. Inadequate Muscle Relaxation –
Contraction of muscle during procedure
Difficulty in Causes pain during port
Pneumoperitoneum insertion
Management –
- Endotracheal intubation
- Pharmacological neuromuscular blockade
- Positive pressure ventilation

57. Anaesthetic Complications :
2. Mask hyper ventilation
Prior to induction 100% oxygen is given by
mask ventilation
Hyperventilation
Distended stomach
Respiratory Dysfunction Liable to injury
during port inser. Or
veress needle inser.
Management –
- Nasogastric tube prior to surgery.

58. Anaesthetic Complications :
3. Air Embolism
CO2 used for pneumoperitonium
Gets absorbed into circulation
Embolus may form and block pulmonary
circulation
• Loud and clear murmur heard in (R) atrium and
(R) ventricle (Mill-Wheel murmur)
Management –
- Direct intracardiac insertion of needle
- Central venous catheter.

59. Management
- Continuous I/V access
- Emergency cart with all resuscitative drugs and
defibrillator.
One should be prepared with –
- Oxygen
- Suction
- Bag and mask ventilation
- Oral and nasal pharyngeal airway, ET tubes of
various sizes.
- Sphygmomanometer
- Electrocardiograph
- Pulse oxymeter

60. COMPLICATIONS DDUUEE TTOO PPNNEEUUMMOOPPEERRIITTOONNIIUUMM
CO2 pneumoperitonium
(a) Gas specific effects (b) Pressure Specific Effects
1. Respiratory Acidosis Excessive Pressure on IVC
2. Hypercarbia
Reduced VR
Reduced CO
Rapid stretch of
peritoneal
membrane
Vasovagal response
Bradycardia, occasionally
hypotension
Management -
• Desufflation of abd.
• Vagolytic (Atropine)
• Adequate volume
replacement

61. Respiratory Dysfunction
Increased pressure pneumoperitonium
Transmitted directly across paralysed diaphragm to
thoracic cavity
Increase Central venous pressure & inc. filling
pressure of (Rt) and (Lt) sides of heart
Management :
• Keep intraabdominal pressure under 15 mm Hg

62. Effects on renal system
Increased intraabdominal pressure
Reduced RBF, Reduced GFR Inc. ADH activity
Reduced Urine output Inc. free water absor.
Inc. plasma renin activity
Inc. Na+ retention
Management :
• Adequate volume replacement at maintenance rate.

63. Pneumothorax
• Due to true diaphragmatic hernia.
• Without any apparent cause.
Diagnosis -
• Presence of rapidly falling Oxygen saturation or
PO2 together with difficult ventilation and
decreased breath sounds.
Management –
• Immediate needle thoracostomy.
• Aspiration
• Chest radiograph
• Placement of chest tube

64. Subcutaneous and Subfascial Emphysema
and Edema
Improper insertion of veress needle
Manipulation of instruments often loosens the parietal
peritoneum surrounding the instruments portal of
exit into the peritoneal cavity.
CO2 then infiltrates the loose areolar tissue of the body
Subcutaneous and sub fascial emphysema
* It rapidly resolves within 2 – 4 hours postoperatively.

67. SSUURRGGIICCAALL CCOOMMPPLLIICCAATTIIOONNSS
Injury to Viscus :
Stomach -Hyperventilation by Mask
Distended stomach
May be injured with trochar or needle
Diagnosis -
• Laparoscopic view of inside of stomach
Management –
• Extend trocar incision into a minilap. for a two
layer closure.
• Laparosocpically
- Pursestring suture or a figure of 8 suture in
the seromuscular layer surround the defect.
- Nasogastric tube drainage for two days.

68. Injury to Viscus :
Bowel - May be injured due to trocar or veress needle
If due to veress needle it is managed conservatively
Diagnosis -
• The emanation of foul smelling gas through
pneumo-peritoneal needle is a helpful diagnostic
sign.
• There may be GI contents at the tip of needle.
Management –
• Mini laprotomy and repair of perforation.
• Laparoscopically it may be sutured of
laparoscopic stapler (ENDO-GIA) can be used.
• Colostomy

69. Injury to Viscus :
Small Bowel Perforation - Most often during
insertion of umblical or lower quadrant trocars
Usually recognized later in the procedure
If adhesions are not freed from anterior abdominal
wall perforation may not be recognized
Management –
• One should consider higher primary site if
adhesions are found through umblical port.
• Perforation repaired transversally
• If injury is free of adhesions bowel can be
withdrawn through 10 mm trocar tract and repaired.

71. Injury to Viscus :
Bladder - Injury caused by second puncture trocar
usually .
Diagnosis : Appearance of gas and blood in Foley’s
catheter bag.
Management –
• Early detection is important.
• Place an indwelling catheter for 7-10 days and
prophylactic antibiotics - If defect is larger.
Repaired by a figure of 8 suture through muscularis
of bladder & second suture to close peritonium
* A water tight seal should be documented by filling
bladder with indigo carmine dye solution.

72. Injury to Viscus :
Ureter - May be injured in adenexal surgeries.
• Thermal injury will result in ureteral narrowing and
hydroureter.
Management –
• Placement of ureteric stent for 3 – 6 weeks.
Incision Hernia :
• Failure to close facial defects from incisions for
secondary trocars.
• Incised fascia should be located with help of skin
hooks and repaired.

73. Vessel Injury :
• Larger vessels may be injured by trocar or veress
needle.
• CO2 peritoneum may tamponade a large vessel
injury.
• When pressure normalizes it starts bleeding.
Management –
• Examine the course of large vessels.
• Overlying peritoneum is opened with laproscopic
scissors or a CO2 laser.
Hematoma evacuated by alternate suction and
irrigation.
* Laprotomy is required if hematoma is expanding or
persistent bleeding.

74. Vessel Injury :
Epigastric Vessels –
• Deep epigastric vessels most frequently injured in
laproscopic hysterectomy.
Management –
By Tamponade –
• By Foley’s catheter
• Bipolar coutery
• Needle suturing
• Small haemostat (Mosquito clamp)
Ovarian or uterine vessels –
• Injured during laproscopic hysterectomy
Management –
• Bipolar desiccation
• Ureter must be identified before desiccation.

75. DDIIAATTHHEERRMMYY RREELLAATTEEDD IINNJJUURRIIEESS
Due to –
• Inadvertent activation of the diathermy
pedal.
• Faulty insulation
Cautery should be used under vision
Injuries –
• Thermal necrosis of organs.
• Inadvertent organ ligation.
• Unrecognized haemorrhage.

76. PATIENT’S FACTORS RREELLAATTEEDD CCOOMMPPLLIICCAATTIIOONNSS
• Obesity
• Ascites
• Organomegaly – organ damage
• Clotting problems – haemorrhage
POST OPERATIVE COMPLICATIONS
• Concealed injury to organs
• Delayed feacal fistula
• Port site metastasis
• Residual air (Referred chest or shoulder pain)

77. CCOONNTTRRAAIINNDDIICCAATTIIOONNSS
Absolute :
• Generalized peritonitis
• Intestinal obstruction
• Clotting abnormalities
• Liver cirrhosis
• Failure to tolerate general anesthesia
• Uncontrolled shock
Relative :
• Multiple abdominal adhesions
• Organomegaly
• Abdominal aortic aneurysm

78.  Robotics
 SILS
 NOTES
 Trocarless laparoscopy
 ENDOBARRIER

79. Leonardo da Vinci
developed one of the
first robots in 1495 –
an armored knight for
the purposes of
entertaining royalty.

80.  Surgeon operates from a 2D image
 Straight, rigid instruments (limited
range of motion)
 Instrument tips controlled at a
distance
 Reduced dexterity, precision & control
 Unsteady camera controlled by
assistant
 Dependent on assistant for surgical
support through accessory port
 Greater surgeon fatigue
 Makes complex operations more
difficult

81. AESOP (Automated Endoscopic System for
Optimal Positioning)
- Voice activated mechanical arm
- Steadier than human, never tires
da Vinci®
- FDA approval in 2002
- Laparoscopic instrumentation controlled by
the surgeon, positioned remotely at a console

82. Defense Advanced Research Projects Agency
(DARPA) for military research of remote
battlefield surgery
 Cholecystectomy performed remotely via telesurgery from 300
miles away
 First robotic prostatectomy performed in 2001

83.  State-of-the-art robotic
technology
 Surgeon in control
 Assistant has direct access

84. WWhhaatt iiss tthhee ddaa VViinnccii®
SSuurrggiiccaall SSyysstteemm??
Surgeon directs precise
movements of instruments
in the slave unit using
console controls.

86.  Laparoscopic instruments
are rigid with no wrists
 EndoWrist® Instrument tips
move like a human wrist
 Allows surgeon to operate
with increased dexterity &
precision. No tremor

87.  Expensive
- $1.4 million cost for machine
- $120,000 annual maintenance contract
- Disposable instruments $2000/case
 Steep surgical learning curve
 Loss of tactile feedback
 Increased staff training/competence
 Increased OR set-up/turnover time!!

88. Past Present

89.  SILS – Single Incision Laparoscopic Surgery
 SSA – Single Site Access
 SPA – Single Port Access
 SAS – Single Access Site
 SPL – Single Port Laparoscopy
 LESS – Laparo Endoscopic Single Site Surgery
 TUES – Trans Umbilical Endoscopic Surgery

90.  Urology
 Renal transplant
 Cholecystectomy
 Gastric band surgery
 Colectomy

93.  Ergonomically difficult ?!
 Training !

97.  No surface incision
 Reduced surgical site infection
 Reduced visible scarring
 Reduction in pain analgesics
 Quicker recovery time
 Reduction in hernias, adhesions
 Advantages in the morbidly obese

99. Video-endoscope entering through the
posterior vaginal fornix

100. NOTES - Transgastric
Courtesy of N Reddy, Hyperbad India 2005

104.  It has not changed the nature of
disease
 The basic principles of good surgery still
apply,including appropriate case selection,
excellent exposure,adequate retraction and
a high level technical expertise
 If a procedure makes no sense with
conventional access, it will make no sense
with a minimal access approach

105.  The cleaner and gentler the act
of operation, the less the
patient suffers, the smoother
and quicker his convalescence,the
more exquisite his healed wound.
Berkeley George Andrew Moynihan