AN INTRODUCTION

TO
LAPAROSCOPIC SURGERY
Contents

1 Prologue
2 Art and craft of laparoscopy
 The equipment
 The technique
 The training
3 A few surgical tips
4 Spectrum of laparoscopy in own set up
5 Conclusion
1- PROLOGUE
• More then 75% of general surgical procedures are being
performed laparoscopically
• We can share at least 30% even today
• Future demands are overwhelming in all fields of surgery
• Keeping well apace with the world
• All technical issues are settled – beyond doubts

The real issue for us

MOLDING THE MINDS & MOVING AHEAD
 Nomenclature
• Conventional open surgery – Wide / large incisions

• Minimally invasive surgery (MIS)

• Minimal access surgery (MAS)
• keyhole surgery,
• Pinhole surgery
• Needle-scopic surgery
Laparoscopy : Minimal invasive abdominal surgery
Incisions = 5- 10 mm

Others MIS:Thoracoscopy /Arthroscopy/ Cranioscopy

The origin of MIS/MAS
Innate Human Desire

Be Minimally Harmed physically

HISTORY
• 460-375 B.C –Hippocrates Exam the rectum with a speculum
• 1901 - George Kelling - Examination of the abdominal cavity of dogs
• 1901 –Jacobeus - surgeon from Stockholm, coined the terms "laparoscopie" and
"thoracoscopie". first to publish a series of abdominal and thoracic examination in
humans using minimally invasive techniques.
• 1911 - Bertram Berheim from Johns Hopkins in to perform the first
laparoscopic examination in the United States.
• 1958 - Fiber optics and the rod-lens system (Harold Hopkins)-
The advent of the insufflators
• 1982 First solid state camera
• In 1985 Germany - Prof Dr Erich Mühe of performed the first laparoscopic
cholecystectomy (LC). 94 procedures
• [1882, Carl Langebuch of Germany - first open cholecystectomy. ]

• 1987 - Phillipe Mouret - in France

Spectrum of MIS
The world of MIS has expanded during the last decade to
include most surgical fields;
• Abdomen and thorax
• Neck
• Brain and heart,
• Gynaecology
• Orthopaedics
Conceptual debates - ISSUES

• Safety
• Economy
• Post-operative pain
• Recovery / Hospital stay
• Visual field for surgeons
• Operation time
• Cosmetic outcome
• Patient acceptance
• The complications
Advantages/ Benefits

 Reduced post operative pain

 Reduced operative trauma
 Reduced bleeding
 Reduced infection, seroma and hematoma
 Reduced chronic wound pain
 Less cardiorespiratory complications
Advantages/ Benefits

 Reduced risk of DVT/PE

 Reduced incisional hernia rate
 Fewer adhesions and less likely to develop obstruction
 Immunological benefits
 Better visualisation for the surgeon Less ileus from
reduced handling
 Improved cosmesis
 Reduced contamination of theatre staff (Hepatitis and HIV)
 Interesting for surgeons
 Reduced outpatient/social costs
 Disadvantages/ Risks

• Same as in open surgery

• Long learning curve
• Some surgeons not able to develop skills
2- The Art & the Craft
of laparoscopic Surgery
Learning the art and the craft
No Compromises
Components of learning
Head / Heart / Hand

A- Affective – Heart / Aptitude/ Willingness / Drive /

Attraction
B- Cognitive - Head / Basic surgical knowledge

C- Psychomotor- Hand / Manual Skill

Psychomotor Components of learning

• THE EQUIPMENT
• THE TECHNIQUE
• THE STRUCTURED TRAINING
The Armamentarium:
Equipment For laparoscopic surgery

 Laparoscopic video system

 Light source
 Insufflator
 Diathermy /coagulation:cutting system
 Suction irrigation system
 Specialized working hand instruments
Panel Trolley
The Equipment For laparoscopic surgery
1. Scope - Laparoscope/video system

Types:
• Telescopic rod lens system, that is connected to a
video camera (single chip / three chip/ HD)
• A digital laparoscope where the charge-coupled
device[CCD] is placed at the end of the laparoscope,
eliminateing the rod lens system.
Telescopic rod lens system
Video camera

Three primary colours (Red,Blue, Green).

Resolution
Depth of Image seen on video screen

Evolution From Single chip to HD & 3D system

Video camera
Video Monitor

• No different from the T.V.

Light source

A fiber optic cable system connected to a

'cold' light source (halogen or xenon), to illuminate
the operative field,
Insufflator for Pneumoperitomeum

Elevates the abdominal wall :

Wide viewing space
Wide working space

Insufflation of the peritoneal cavity with Carbon dioxide gas

. Gasless surgery –with mechanical wall elevators
Coagulation & Cutting System

1-Diathermy
mono-polar / bi-polar
2-Piezoelectric Coagulation & Cutting devices
Piezoelectric coagulation /cutting devices

HARMONIC system – by Ethicon

 Converts the Electrical signal to Mechanical vibration .

 This ultrasonic vibration is amplified
 Will permit tissue ablation, cauterization or cutting.
 Precise control of tissue ablation
 Minimal disturbance to surrounding tissue structure.
Piezoelectric coagulation /cutting devices

THUNDERBEAT by Olympus

Integrate both advanced bipolar and ultrasonic energy

Specialized hand / working instruments

 Access making instruments

 Dissecting/operating instruments
 Cutting and stapling instruments
 Others - supportive
Specialized hand instruments

• Disposable vs Reusable instruments

• Multiple port vs Single port instruments
• Conventional larger vs. Needle scopic
[miniaturized instruments—2mm size]
Specialized hand instruments
5-10mm diameter instruments
• Trocars & Ports---access devices
• Graspers
• Scissors
• Dissectors
• Clip applier,Knotting devices,Staplers
• Cutting /coagulation
hooks,spatulas,balls,forceps
• Irrigation suction tubes
• Retrieval instruments
Veress Needles
Trocars
To make the ports for dissecting and other instruments
Scissors
Dissectors
Graspers
Hook & Spatula
Trays
Diathermy / Harmonic dissector
Clip applicator
Irrigation suction instruments

All in one unit

Retrieval instruments
Other Equipments

• Staplers
• Knotting devices
• Suturing devices

The first step in Learning Laparoscopy

Getting familiar with the specialized Equipment
Basic principles of Scopic Surgery
Surgical goals to achieve
Indications for surgery Same as in open surgery
Pre-operative assessment
Pre-operative preparations
[ with special consent]
Access - minimal cutting
Field of vision during surgery - wider and
broader
Instrumentations and technique - Specialized
Steps of surgery - Almost same as in open surgery
Post operative care - Same as in open surgery
The training in laparoscopic surgery

Specialized training with Steady learning curve

 The learning curve: Step by step learning

Different Institutional protocols of teaching and learning

Aims and objectives of learning remain same
Simulator Training-Endotrainers
Simulator Training-manikins
Module I.
Preoperative Considerations

• Patient Selection /surgical indications

• Preoperative Assessment
• Preparation
• Laparoscopic Equipment
• Energy Sources
• OR Set Up
Module II.
Intraoperative Considerations

• Anesthesia
• Patient Positioning
• Pneumoperitoneum Establishment /Physiology of
Pneumoperitoneum
• Trocar Placement
• Exiting the Abdomen

Compare it with learning steps in open surgery

How do you allow your trainees

to proceed in open surgery ?
Module III. Conducting the procedures

Basic Laparoscopic Procedures& techniques

• Diagnostic Laparoscopy
• Biopsy
• Laparoscopic Suturing
• Hemorrhage & Hemostasis
Module III. Conducting the procedures

Conducting Laparoscopic Procedures

Basic vs advanced
Assissted / Supervise/ Independent
Module IV.
Postoperative Care
• Postoperative Care
• Surgical Injuries
• Complications and Dealing with.
Module V.
Manual Skills Instruction
and Practice
• Training Exercises
• Record and audit/Data Analysis
• Research
3- A few Surgical tips
Principles of laparoscopic surgery

Principles of patient selection, Indications for surgery and

preparation are almost same as for the open surgery

The main difference is

The technology and the technique
used in the surgical procedures

Principles of Post-operative care are also same

•
Seven ladders of surgical management
1. Diagnostic work up
2. Assessment
The disease process
The patient as whole - body systems
3- Pre-operative preparations
General – counseling and consent
Specific
4- Operation-the art and the craft
5- Post operative care
Early/ subsequent
6- Follow-up
7- Audit
Laparoscopic Cholecystectomy

1. Diagnostic work up 1. Indications – The GB Problem-?

2. Assessment 2. Patient selection
The disease process
The patient body systems
3- Pre-operative preparations 3. Preparation
General – counseling/ consent Consent/special features
Specific
4- Operation-the art and the craft 4. Procedure/technique
5- Post operative care
5. Post-operative care
Early/ subsequent
6- Follow-up
6- Complication
7- Audit
7- Video and written Records
Before you start the procedure

• Check the camera / video system

• Check the diathermy
• Check the gas Pressures
• Check the abdominal wall
• Plan the Incisions for ports
Positioning and setting the instruments
Approach for Access ports
Planning the incision in open surgery vs planning the ports for access

For different procedures – the access ports are at different sites

Practice what you are trained in

Pneumoperitoneum
Open method
 Open the peritoneal cavity Under vision
 Sub umblical , through the ublicus , any other site
 Safest

Close Method - Veress needle

Inspection -Diagnostic Laparoscopy

Mandatory
• Primary area of concern
• Rest of the cavity
• Resectability
• Adhesions
Procedural safety-Cholecystectomy

• Stay close to gall bladder

• Dissect in “lateral to medial direction”
• Dissect lateral to Lymph node to make window in Calot’s triangle
• Clearly define the junction of cystic duct with GB
• Do not attempt defining the junction of cystic duct and CBD
• Don’t look at the watch
• Sever upon Allah before you clip and cut – that is it right ?
• Don’t be in panic – bleeding : apply pressure, think & plan
• Beginners: keep a low threshold for conversion to open

• Protect the gut – don’t touch with coagulating instrument

Concluding the operation

• Re-inspection – bleeding or bile

• Irrigation suction
• Drain
• Deflation – [ surgical emphysema can
occure]
• Check the ports
• Close the incisions – especially umblicus
Carefully collect the
instruments/equipment
4-Spectrum of Laparoscopy in our set up
Spectrum of Laparoscopy in our set up

India has moved many steps ahead

1. DIAGNOSTIC
2. THERAPEUTIC
Spectrum of Laparoscopy
Diagnostic Therapeutic
• TB Cholecystectomy
• Crohn’s disease Appendicectomy
• Diverticulitis Hernia repair
• Lymph-adenopathy Adrenalectomy
• Some Splenic disorders Bowel resection
• Malignancies Gynaecological
• Post operartive – dyspepsia and Post operartive - adhesions
pain syndromes Splenectomy
• Gynaecological Repair of Prolapse
Nephrectomy
• Trauma – open venue Gastric by pass bypass
against DPL & minilap Bariatric surgery
Diagnostic value
Pain lower abdomen in young soldier
Diagnostic value
Pain lower abdomen in Teenage Girls
Diagnostic value
Pain lower abdomen in Teenage Girls
Diagnostic value
Pain lower abdomen Women of child bearing age

• Chronic Ectopic Pregnancy

• PID – [ e.g. Gonorrheal ]
• Primary and Secondary Infertility
Diagnostic value
Post laparotomy Pain
The Growing Spectrum of MIS

TELEROBOTICS

1994 --- the introduction of robotics into the operating

room.
A robotic arm was used to hold the camera
replacing the camera operator.

1996- a surgery was performed with the patient and

surgeon in different locations using the Internet -
Telesurgery
5-Conclusion

 Learn the craft fully before you work independently

 Do not embark upon a case – if unable to deal with complications
 Be humble – there is always a new case to see and learn

National need
Structured training set ups
University and CPSP level training programs
Diplomas
Fellowships
Thank you