TEHNIK DASAR LAPAROSKOPIK:

PNEUMOPERITONEUM,
VERESS NEEDLE,
INSERSI TROKAR, TEKANAN GAS, DLL

Dr. dr. Ronald E. Lusikooy, SpB-KBD

 PNEUMOPERITONEUM

“Safe Technique”

(Patho) Physiology

Potential Complication
 (PATHO) PHYSIOLOGY
PNEUMOPERITONEUM CO2
Perubahan terjadi waktu laparoskopi,
akibat:
• Anestesi Umum
• Positive Pressure Ventilation
• Posisi Pasien
• Efek Mekanik
• Neuro Endokrin
Kardiovaskuler • Immunologi Dari
• Pneumoperitoneum dan CO2 yang diabsorbsi
 (PATHO) PHYSIOLOGY
PNEUMOPERITONEUM CO2

Kardiovaskuler
• Phase initial cardiac index turun 50%, 10 – 15 menit
kemudian membaik (peran catecholamine)
• Pneumoperitoneum CO2: HR ↑, MAP ↑, system
vascular resistance dan CO ↓
 (PATHO) PHYSIOLOGY
PNEUMOPERITONEUM CO2

Respiratory

• Compliance dan functional residual capacity karena

elevasi diaphragma ↓
• Kadang-kadang terjadi hypercapnia (absorbsi CO2)
 KOMPLIKASI PNEUMOPERITONEUM

Subcutaneous emphysema, melalui mediastinum sampai ke

leher

Hemodynamic compromise karena tekanan intra abdominal

↑ (10 – 12 mmhg) 🡪 venous return ↓

Massive CO2 gas embolism (lethal dose 25 ml/kg CO2)

masalah tekanan intra abdominal
• tekanan intra vaskular ↑ 🡪 venous embolism ↓
• desaturation, hipotensi, “mill wheel murmur”
PENATALAKSANAAN GAS EMBOLISM

•Posisikan pasien “leftlateral head down”

•Insufflasi gas stop
•Pneumoperitoneum dikempeskan
•Naikkan inspirasi o2 ke 100%
•Vasopressors
•Aspirasi gas di jantung kanan
 GAS INSUFFLASI

CO2 : “least noxious”, high solubility,

not support-combustion
Udara, N2O, Helium
 METODE

Veress needle

•Veress needle dan trocar I dimasukkan “blindly”

•Cedera bisa terjadi pada usus, hati, aorta, vena cava,
pembuluh darah mesenterial, dsb.
•Cedera usus 0,06 – 0,5%, cedera pembuluh darah 0,05
– 0,3%
•Mortalitas cedera pembuluh darah besar 17%
•Insidens rendah, tapi bermakna (Hasson 1971)
 METODE

Teknik hasson (“open technique”)

• Mini laparotomi ± 1 cm
• Cedera vaskuler dan viseral
ada, tapi secara umum
dianggap “safe” (hanney 1999)
• Trokar “troc doc” memudahkan,
aman dan mencegah
kebocoran.
 PNEUMOPERITONEUM

Vertical incision in the umbilicus

(1 cm), only penetrating the skin

Semi Lunar Incision

VERRES NEEDLE
 PNEUMOPERITONEUM

By Grasping Elevation By Clamp Elevation

• Verres Needle is inserted through the umbilical incision

• Patient should be in 25-35° Trendelenburg position
 PNEUMOPERITONEUM

Anterior abdominal wall is Aspiration of verres needle to

elevated ensure safety of insertion
 PNEUMOPERITONEUM

• Needle is connected to a pressure-regulated CO2 insufflator

• Flow is begun at 1 liter/minute.
• Opening intra-abdominal pressure should be 5 mmHg or less
 TROCARS INSERTION SITES

▪ Umbilicus
▪ Midline 5 cm below the
xiphoid process
▪ Midclavicular line 2 cm
below the right costal
margin
▪ Right anterior axillary line
at the level of umbilicus
 TROCAR INSERTION
Disposable trocar with safety shield

▪ Anterior abdominal wall is elevated by left hand

▪ 10/11 mm trocar is inserted through the umbilicus by right hand
▪ Trocar aiming at coccyx & kept in the midline
DISPOSABLE TROCAR
 TROCAR INSERTION

A twisting action
Primary trocar is
can be used to
inserted
gain steady entry
 PRIMARY TROCAR INSERTION

Always pointing the tip towards the pelvis to minimize

visceral or vessel injury
 POSSIBILITY OF HEMORRHAGE FROM
TROCAR SITE

Trocar insertion
may injure blood Bleeding may
vessels in the occur
site
To avoid vessel
If hemostasis injury,
can’t be attained, transillumination
the vessel must helps to visualize
be suture-ligated vessels in the
abdominal wall
 ADDITIONAL TROCAR INSERTION

•Second trocar insertion through direct visualization, until the

tip pierces the peritoneum
•Then angle the trocar horizontally to avoid visceral injury
 POSSIBILITY OF TROCAR INJURIES

The safety shield of the

secondary trocar is not
retracted 🡪 It may cause
injury to the internal
organs

a.
To avoid injury 🡪 the
secondary trocar should
be directed at the primary
trocarcal b.
POSSIBILITY OF TROCAR INJURIES

Trocar is hung up in the preperitoneal space

 Possibility of Trocar Injuries

Faulty direction of trocar tip

could lead to visceral injury

Major vascular injury 🡪 This

requires immediate
laparotomy
 TROCAR INSERTION
Hasson Technique

•Patient with history of lower abdominal surgery, umbilical

entry maybe unsafe due to underlying adhesion
•An Open Technique maybe performed : Umbilical incision
until peritoneum is visualized and opened
THEDISPOSABLE
TIP OF HASSON TROCAR
TROCAR
 TROCAR INSERTION
Hasson Technique

Hasson trocar is inserted through the umbilical incision

LAPAROSCOPE INSERTION
 PASIEN-PASIEN KHUSUS
Pasien ASA III/IV
•Cardiac index 🡪do2 , hypercapnia.

Wanita hamil
•Kehamilan trimester ke 2 atau diatas
10 mgg
•Posisi “left or right lateral tilt”
•Tekanan intra abdomen 🡪 kompresi
Anak/Paediatri
aortocaval
•Tekanan pneumoperitoneum
•serendah
“Insufflation flow dan tekanan
mungkin
pneumoperitoneum lebih rendah dp
dewasa : 2 l/min dan 8 – 10 mmhg”