Describes basics of laparoscopy and basic instruments

1. Basics of laparoscopy
Anirudha Doshi

2. • Laparo means abdominal cavity
• Scopy means to see

3. History
• 1902: Georg Kelling of Dresden: performed the
first laparoscopic procedure on dogs.
• 1910: Hans Christian Jacobaeus of sweden: the
first laparoscopic operation on humans.
• 1980: Patrick steptoe, performed 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.

4. History
• 1983- First laparoscopic appendicectomy
Semm, a german gynacologist.
• 1985- First Lap Cholecystectomy Erich Muhe a
german surgeon.
• 1987- First Laparoscopic repair of inguinal
hernia by Ger.
• 1989- First lap hysterectomy, Reich et al.

5. Advantages
• Less pain, less hospital stay, minimal scar, early
ambulation, magnified view, reduced risk of
acquired infections, less chances of incisional
related complications
• Disadvantages: Requires long learning curve

6. Contraindication
• Patient related
• Absolute: Unfit for GA, Hemodynamically
unstable
• Relative: Cardiopulmonary disorders, DVT,
Renal disorders, Pulmonary
thromboembolism, cirrhosis, Acute ntestinal
obstruction with gross distension, Abdominal
TB, Multiple surgeries

7. • Trauma with hemoperitoneum, malignancy,
pregnancy are not considered as
contraindications in expert hands.

8. Physiological changes
• Mechanical effect: Pneumo peritoneum may
compress venous capacitance vessels causing
an initial increase, followed by a sustainted
decrease in preload.
• Compressing of the arterial vasculature
increased after load and may result in marked
increase in calculated systemic vascular
resistance.

9. • CO2 Absorption: Significant hypercapnia and
acidosis may occur during laparoscopy causes
decrease in myocardial contractility, arteriolar
dilation, catacholamines release.
• Neurohumoral: vassopressin and
catecholamines release, stimulates
sympathetic mervous system activating renin
angiotensin system.

10. • Airway management: Controlled mechanical
ventilation, ET tube CO2 monitoring,
adequacy of ventilation,

11. Renal
• Oliguria is expected due to rise in intra abdominal
pressure.
• At 15mm Hg, there is significant decrease in GFR
of 63 to 64%.
• Over resuscitation, fluid overload, pulmonary
edema can exacerbation of congestive heart
failure.

12. Patient Position

14. General requirements
• Optical System: Camera, Telescope, Processor
Monitor
• Light Source & Cable
• Insufflator
• Instruments
• Energy Sources

16. Camera
• 3 chip(red, green, blue)
• 1080 pixels resolution
• The camera head consists of a goal lens, a
prism assembly and three sensors for
acquiring the primary colors of the image.
• Optical zoom is advantageous to prevent
negative effect of on look resolution.

18. Telescope
• 5mm, 10mm size usually
• Hopkin’s Rod and lens system
• 460mm length
• Angles 0, 30,45

20. TV Monitor
• Usually 20 inches.
• HD TV is better
• Preferable with video recorder.

21. Light Source
• Halogen/ xenon/ LED cold lights
• 3200K/4000K/4000K
• Life: 200-400hrs/2500hrs/5000hrs
• Fibre light cable, condensers
• White balance by making sure white is correct
then all the colors through the spectrum are
correct.

23. Insufflator
• CO2 is being used because same refractive
index as air, doesn’t distort the image and is
non combustible.
• Intra abdominal pressure 10 to 13 mm hg.
• Complications of CO2: extra peritoneal gas
insufflation, gas embolism, cardiac arrythmia,
post operative peritoneal irritation,
hypercarbia

25. Access of insufflation
• Open technique: Hasson Cannula
• Closed technique: Veress needle

26. Hasson cannula

27. Veress Needle
• 1938 Jans Veress of hungary developed the
spring loaded needle to perform pnuemothorax.
• Surgical stainless steel with single trap valve.
2mm diameter X 75mm/150mm length.
• Aspiration test, hanging drop test, free flow of
saline.

30. • Palmar point: 3 cm below the left subcostal
border in midclavicular line.
• Infra/Supra umbilicus
• Epigastric region in midline
• Complications: injury to blood vessel, bladder,
bowel, solid organs, surgical emphysema

31. Trocar
• Surgical instrument fitted with cannula into
body cavity.
• Blade with shaft and body.
• Diameters 3mm-30mm
• Type: Cutting . Pyramidal tipped
. Flat blade
• Non Cutting . Pointed conical. Blunt conical .
• Optical Trocar

33. Instruments

37. Thunderbeat/Ligasure/Harmonic
Energy system Visibility Operation time
Burst pressure
Thermal spread
Thunderbeat Unimpaired visibility Fastest in class
cutting
Highest mean burst pressure
Least lateral thermal spread
LVSS Smoke production
affecting visibility
Slow surgery Moderate mean burst
pressure 2 mm lateral
thermal spread
HS Mist production
affecting visibility
Slower surgery Lowest mean burst pressure
Less than 1 mm thermal
spread
World Journal of Laparoscopic Surgery, January-April 2014;7(1):41-44

38. Thunderbeat/Ligasure/Harmonic
It simultaneously delivers
ultrasonically generated
frictional heat energy and
electrically generated bipolar
energy.
It seals tissue by
administration of high current
and low voltage that of 180 V
The HS is a high power system
which works at a frequency of
55.5 KHz or 55,500
vibrations/sec
Can achieve 7 mm vessel
sealing.
Seal of blood vessels
measured up to 7 mm
diameter
The shear can coagulate
vessels up to 5 mm, whereas
the hook and blade only 2 mm
in diameter.
five variables: hemostasis,
histologic sealing, cutting,
dissection and tissue
manipulation.
A high coaptive pressure
during the generation of tissue
temperature under 1000°C,
hydrogen cross-links are first
ruptured and then renatured,
resulting in a vascular seal that
has high tensile strength.
Melted collagen and elastin in
the vessels forms a permanent
plastic like seal.
The ultrasound (US)
transducer located in the
handpiece is composed of
piezoelectric crystal
sandwiched under pressure
among metal cylinders. The
sealing of the vessels is
achieved due to denatured
protein coagulum which
occurs due to tamponade and
coaptation.

39. Lap. In malignancy
• Malignancy is not a contraindication for lap. In
safe hands and if principle of oncosurgery
(minimal handling of tumor, prevent spillage,
avoid sudden trocar removal).
• Chances of port site metastasis is same as
open surgeries.

40. Lap. In Pregnancy
• Conservative management is more harmful for
fetus then operative for inflammatory
pathologies.
• Disadvantages: Fetal Distress, decrease blood
supply to uterus.
• Advice: Keep low Intra abdominal pressure.

41. Complication of laparoscopy
• Access related: Hollow visceral injury, solid
organ injury, vessels
• Surgical related: Vascular injury, hollow
visceral injury, ureteral injury.
• Pneumo related: hypercarbia, gas embolism,
DVT, post operative peritoneal irritation.
• Cautery related: Direct: Injury to viscera
Leak, capasitive coupling.

42. Ergonomics of laparoscopy
• Baseball principal

43. • Sectorization

44. • Surgeon
Table height to be upto level of elbow,
Screen to be at head level,
6 feets away from surgeon.

45. Lap. Cholecystectomy/Right Colectomy

46. Lap. Gastric surgery/Lap. Spleenectomy

47. Lap. Appendectomy/ Lap. Sigmoid

48. Lap. Inguinal hernia/ Lap. Umbilical, incisional

49. Recent advances
• Natural orifice translumenal endoscopic surgery
(NOTES)
• The SPIDER is a sterile and disposable device that
contains 4 working channels (2 flexible
instrument delivery tubes positioned laterally and
2 rigid channels, superiorly and inferiorly to
accommodate an endoscope or any of the shelf
rigid surgical instruments).
• 100 cases with the SPIDER, including colectomy,
cholecystectomy and adjustable gastric banding.

51. Single port(SILS)
• The tenet of single-incision laparoscopic surgery is to
lessen the quantity of incisions to one, typically at the
umbilicus, for multiple trocar placements.
• The necessary proximity of the trocars in a fixed
position illustrates among the disadvantages of those
techniques.
• The freedom of the hands is comparatively restricted,
which causes clashing from the instruments, and also
the fixed port in the umbilicus potentially creates an
extended distance towards the surgical site.