PRINCIPLES OF

LAPAROSCOPIC &
ROBOTIC SURGERY
Aaquila Sherin
Bismi J J
Blessy Oomman
DEFINITION
• Minimal access surgery is a product of modern technology and
surgical innovation that aims to accomplish surgical therapeutic goals
with minimal somatic and psychological trauma.
Core Principles Of Minimal Access Surgery
• I-VITROS
• I-Insufflate/create space-To allow surgery to take place in the
minimal access setting.
• V-Visualise-The tissues,anatomical landmarks and the environment
for the surgery to take place.
• I-Identify-The specific structures for surgery.
• T-triangulate-Surgical tools to optimize the efficiency of their action
and ergonomics by minimizing overlap and clashing of instruments.
• R-retract-and manipulate local tissues to improve access and gain
entry into the correct tissue planes.
• O-Operate-Incise,suture,anastomose,fuse
• S-Seal/Haemostasis
Types of Minimal Access techniques

• Laparoscopy
• A rigid endoscope(laparoscope) is introduced through a port into the
peritoneal cavity .
• His is insufflated with carbon dioxide to produce a
pneumoperitoneum.
• Further ports are inserted to enable instrument access and their use
for dissection.
Thoracoscopy
• A rigid endoscope is introduced through an incision in the chest to
gain access to the thoracic contents.
• Usually there is no requirement for gas insufflation as the operating
space is held open by the rigidity of the thoracic cavity.
• In specific cases such as medistinal tumour resection and
diaphragmatic surgery,gas insufflation at low pressure (5-8 mmHg)
may be applied.
Endoluminal Endoscopy
• Flexible or rigid endoscope are introduced into the hollow organs or
systems,such as the urinary tract,upper or lower GI tract,and
Respiratory and vascular systems.
Perivisceral Endoscopy

• Body planes can be accessed even in the absence of a natural cavity.

• Eg:Mediastinoscopy,Retroperitoneoscopy and Retroperitoneal
approaches to the kidney,Aorta and Lumbar sympathetic chain
Arthroscopy and Intra-Articular Joint
Surgery
• Orthopaedic sugeons have applied arthroscopic approach to the knee
and other joints.
Combined Approach

• The diseased organ is visualized and treated by an assortment of

endoluminal and extraluminal endoscopes and other imaging
devices.Examples include the combined laproendoscopic approach for
the management of biliary lithiasis,colonic polyp excision.
Advantages of Minimal Access Surgery

• Deacrease in wound size.

• Reduction in wound infection,dehiscence,bleeding,herniation and
nerve entrapment.
• Decrease in wound pain.
• Improved mobility.
• Decreased wound trauma.
• Decreased heat loss.
• Improved visualization.
Limitations

• Reliance on remote vision and operating.

• Loss of tactile feedback.
• Dependence on hand-eye coordination.
• Difficulty with haemostasis.
• Reliance on new techniques.
• Extraction of large specimens.
ROBOTIC SURGERY

• A robot is a mechanical device that performs automated physical

tasks according to direct human supervision,a predefined pogram or a
set of general guidelines,using artificial intelligence techniques.
• First cinical use in 1985 with PUMA 560 used for brain biopsy.
Robotic surgical systems exists as 2 main categories:
1.Teleoperated systems
2.Image guided systems
Teleoperated systems

• A human surgeon performs an operation via a robot and its robotic

instruments through a Televisual computerized platform ,either via
onsite connections or remotely through the internet or other digital
channels.
Image guided systems

• A surgical robot completes a pre programmed surgical task which is

guided by pre operative imaging and real time anatomical constraints
and cues through the application of inbuilt navigation systems.
Preoperative Evaluation
• History
• Examination
• Premedication
• Prophylaxis against Thromboembolism
• Urinary catheters
• Nasogastric tubes
• Informed consent
Theatre Set Up and Tools

• Equipment consists of atleast 2 high resolution Liquid Crystal

Display(LCD) monitors,the laparoscopic kits for maintaining
pneumoperitoneum and the audiovisual kit.
General Intraoperative Principles

• Creating a pneumoperitoneum-There are 2 methods for creation of

pneumoperitoneum:Open and closed.
• The closed method involves blind puncture using a Verres needle
• The routine use of the open technique for creating a
pneumoperitoneum avoids the morbidity related to a blind puncture.
• To achieve this,a 1cm vertical or transverse incision is made at the
level of the umbilicus.
Pre Operative Problems

• Previous abdominal surgery

• Obesity
Operative Problems
• Intra Operative perforation of a viscus.
• Antibiotics to manage known sepsis or septicemia in a patient
undergoing surgery.
• Antibiotics to prevent infections and sepsis.
• Bleeding.
Bleeding:

Risk factors that predispose to increased bleeding include:

• Cirrhosis
• inflammatory conditions
• patient on clopidogrel and dipyridamol
• coagulation defects.
How to avoid bleeding?

o Bleeding from a major vessel:

• Damage to a large vessel requires immediate assessment of the
magnitude and type of bleeding.
• When a bleeding vessel is identified,a fine tip grasper used to grasp it
and apply either electrocautery or a clip depending on its size.
• When the vessel is not identified early and pool of blood is
formed,immediate compression with a blunt instrument,cotton swab
or with the adjacent organ.
• Surgicel (absorbable fibrillar oxidase cellulose polymer) or other clot
promoting strips,tissue glues or othe haemostatic agents used
laparoscopically to aid haemostasis.
• If bleeding is difficult to control,there should be no delay in converting
into an open procedure.
Bleeding from organs

• Intra operative bleeding from organs can be prevented by performing

the dissection in the correct plane.
• For eg: in case of laparoscopic cholecystectomy:
• When a bleeding site appears during detatchment of the gall
bladder,dissection should be carried liitle farther to expose the
bleeding point adequately.Direct application of electocautery usually
controls the bleeding.
Bleeding from a Trocar Site

• Bleeding from the trocar sites is usually controlled by applying

upwards and lateral pressure with the trocar itself.
• After the procedure has been completed the loop is removed under
direct laparoscopic visualization to ensure complete haemostasis.
Evacuation of Blood Clot

• Best way to dealing with blood clot is to avoid them.

• The routine use of 5000-7000 units of heparin per litre of irrigation
fluid,helps to avoid the formation of clots.
• After clots have formed a large bore suction device should be used for
their retrieval.
• Care should be taken to avoid suctioning in proximity to placed clips.
PRINCIPLES OF ELECTROSURGERY DURING LAPROSCOPIC SURGERY

• Electrosurgical injuries during laproscopy are potentially serious.

• Majority occur following the use of monopolar diathermy
• electrical injuries are usually unrecognised at the time that they occur,
with patients commonly presenting 3-7 days after the injury with
complaints of fever & abdominal pain.
• Theories are:
inadverdent touching or gasping of tissue during current application
direct coupling between a portion of bowel and a metal instrument
that is touching the activated probe
Insulation breaks in the electrodes
direct sparking to the bowel from the diathermy probe
current passage from the bowel from recently coagulated, electrically
isolated tissue
• bipolar diathermy is safer and should be used in preference to
monopolar diathermy especially in anatomically crowded areas.
• if monopolar diathermy is to be used then safety measures
likeattainment of perfect visual image, avaoiding excessive current
application and meticulous attention to insulation.
• alternative methods of performing dessection like use of ultrasonic
devices may improve safety.
POSTOPERATIVE CARE

• Most common postoperative are a dull upper abdominal pain,

nausea, and pain around the shoulders(referred from diaphragm)
• there has been some suggestion that the instillation of local
anaesthetic to the operating site and into the suprehepatic space or
even leaving 1 L of normal saline in the peritonium serves to decrease
postoperative pin.
• if the patient develops a fever or tachycardia or complains of severe
pain at the operation site then routine investigation should be done
which include full blood count, CRP, LFT, amylase test and an
ultrasound of upper abdomen to detect fluid collection
• if bile duct leakage is suspected, endoscopic retrograde
cholangiopancreatography (ERCP) may be needed
 NAUSEA
usually responds to an antiemetic such as ondasetron and settles
within 12-24 hrs

SHOULDER TIP PAIN

pain referred from the diaphram and relieved by simple analgesics
(paracetamol)
ABDOMINAL PAIN
increasing pain after 2-3 days may be a sign of infection and with
concomitant signs, antibiotic therapy occationally required.
herniation through a port may account for localised pain- Richter’s hernia
ANALGESIA
a 100mg diclofenac suppository may be given at the time of operation.
suppositories may be administered further 2-3 times postoperatively for
relief of more severe pain (otherwise 500-1000mg of paracetamol 4
hourly usully suffices)
• opiate analgeses- used unless the pain is very severe

OROGASTRIC TUBE
it should be removed as soon as the operation is over and before the
patient regains the consciousness.
URINARY CATHETER
catheter should be removed before the patient regains concsiousness, should be
warned about symptoms of post operative cystitis.

DRAINS
if a drain is placed it should be removed within 12 hr of the operation
excessive hepatic bleeding or bile leakage- should be removed when problem
has been resolved (usually after 12-24 hrs)
continous blood loss from a drain indicate reexploration of abdomen
DISCHARGE FROM HOSPITAL

• they should be advised to return to the hospital if they develop

abdominal pain or other severe symptoms.
 Skin Sutures
non absorbable sutures or skin staples if used- removed after 7 days
 Mobility & Convalescence
since these are painfree compared to open operations the patient can
get out of bed and meet his basic needs.
patient can cough actively and clear bronchial secretions- helps to
diminish chest infections
• DISADVANTAGES
• increased cost
• increased setup of the system and operating time
• socioeconomic implication
• significant risk of convertion to conventional techniques
• multiple repositioning of the arms can cause trauma
• hemostasis
• collision of the robotic arms in extreme positions
SINGLE INCISION LAPROSCOPIC SURGERY

• its a technique adopted to insert all the instrumentations via a single

incision through a multiple channel port via the umbilicus to carry out
the procedure.
• benefit is that:
• only one incision through a natural scar(umbilicus) is made therefore
theses are virtually scarless
• less port sites around the abdomen have the potential for less pain,
less risk of port site bleeding and reduced incidence of portsite
hernia
• other synonyms:
• laproendoscopic single site surgery (LESS)
• sinle port access surgery(SPA)
• it does require specially manufactured multichannel ports and often
reticulating instruments
• better cosmetic outcome and even less pain in the immediate post
operative period
NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC
SURGERY
• in this technique, where surgeons enter the peritonial cavity via
endoscopic puncture of a hollow viscus.
• the closure of the visceral puncture site is the issue that really has
prevented widespread uptake of the technique
• also the equipments needed has significant cost and requires a large
number of practitioners in the team
THANK
YOU