Contents Pets i Section 1: Introduction Introductonhistory, 3 Definition, 4 ‘dranage of lapaconcopy 4 Disadvantages and imiation of laparoscory, 5 Contrsindiationsik factory 6 Combined laparoscopy and open surgery, 8 Physiological changes during parscopy, 9 Anaesthesia during laparoscopy, 13 Postoperative management, 3, Section 2: Equipment, instruments, basic techniques, problems and solutions Equipment, 17 Problems and volsions with imaging and viewing, 20 Steriation and maineenance of opis and camer, 32 Instrumens and acon, 22 Creation of peumopertoneun/aces, 30 Castes paroscopy. 31 Poeumoperconeum by Vers eee, 32 Problems and voltons of Ves nedle and poeumopeitoneum, 36 Peiaary Canela neton (rr anol), 99 Problems and soltions of primary ean, 42 (Open cannulation (Hasson tecbgue), 46 Secondary cannula (working annul, accessory canna), 48 Problems and soltons 52 Recaction, $5 Exeapeioneal laparoscopy, 56 Inset holden 60 tng fom the abdomen, 60 lesruments for dssection, 6 Diathermyllecrocastey, 65 Distecton ofa 65 Huemonasis, 71 Sociowigaion, 72 ase, 73, High intensity focused ursound, 76 High velocity water et, 78 Hydrodisecton 78 gation and suturing, 78 Specimen action 9 Section 1 Introduction Ineroduction/history Introductionihistory “The recent upsurge in the practice of laparoscopic surgery and other forms of minimal access surgery” as ushered in anew era of ueical ‘treatment which ishaving profound effets on surgical management cos the various specialitis. Although the new approach has been initiated by adule general surgeons and gynaecologist, there is increasing imerestin performing laparoscopicleadoscopic procedures im other specialities, such as paediatric surgery, wrology, orthopaedic surgery, otorhinolaryngology, cardiovascular surgery, neurosurgery and plastic surgery. ‘The idea of minimal access surgery is not new; the use of tube and speculum in medicine dates rom the earliest days of <ivilzation in Mesopotamia and ancient Greece. Modern endoscopy sarted in 1805, when Bozzni an obstetrician fom Frankfurt, using candlelight ‘through a tube attempted to examine urethra and vagina in patients. In 1897, Nitze, a urologist from Berlin working with Reinecke, a Berlin optician, and Lets, a Viennese instrument maker, produced the first usable eystoscope with lenses and platinum wire for iluminaton. In x902, von Ox from Se. Petersburg reported the frst abslominal cavity inspection, by focusing ahead mirror into aspect lum. A yar later Kelling, using aeystoscope ater insulation with filtered ais eported laparoscopy in a living dog to a meeting in Hamburg. In 1910, Jacobacus,a surgeon from Stockholm, performed laparoscopy and thoracoscopy inhuman using a eystoncope-Throogh- ‘out the 1920s and 19308, Kalk; the founder ofthe German School ‘of Laparoscopy, who developed many purpose-designed instruments including obtique-iewing optics, popularized diagnostic laparoscopy in disorders ofthe liver and biliary tract and opened the way forthe development of operative laparoscopy. Subsequent, laparoscopy was developed for gynaecological practice by Palmer (France), Frangenheim and Semm (Germany), Steptoe (UK) and Philips (Usa, “The introduction of fibre-optic light, and the development ofthe rod ens system by the British physicist Hopkins in 1952, led to ‘dramatic worldwide increas in the we of telescopes in general and laparoscopes in particular, ‘The origin of modern laparoscopic surgery is derived from the Kiet School in Germany headed by Semm, a gynaecologist. This centre developed and refined many instraments and established most laparoscopic gynaecological. procedures currently in. practice. Although in use by gynaecologists now for many years, general surgical operations were slow eo fall to laparoscopic procedure, 3 Section 1: Introduction Laparoscopically guided gal stone clearance was frst performed in an animal model by rimberger and associates in Germany in 1979. Semm and his group described the technique of a laparoscopic appendicectomy without recourse t0 minilaparotomy in 198 ‘Muehe,a surgeon from Boblingen in Germany introduced cholecys- tectomyy into clinical practice using a modified recoscope and CO, suflation in 1985. The latest highly sgnfican advance was the introduction ofthe compute chip video camera in r986 which ignited the development of today’s laparoscopic surgery. In 1987, Mouret, in Lyon (France) was the frst surgeon to perform cholecystectomy in the human using standard laparoscopic equipment. The fst published eport ofthe current mukipuncture cholecystectomy was by Dubois in Paris, France in 1989. Around che same time, the procedure was established by Peisat (Bordeaux, France), Reddick tal, (Nashville, USA), Cuschieri and Nathanson (Dundee, UK) land Berci et al. (Los Angeles, USA). Since then, the practice of laparoscopic surgical procedureshas mushroomed acrosthe various specialities, There can be litle doubt chat many aspects of the current technology and instrumentation can and will be improved in the ‘near future, thereby increasing the ease of performance and scope of this typeof (minimal acces) surgery Definition Laparoscopy isthe inspection of the peritoneal cavity by means of a telescope introdoced through the abdominal wall after creation of a ‘pneumopertoneum. Laparoscopic surgery isthe execution of established surgical procedures in a way which leads tothe reduction ofthe trauma of access and thereby accelerates the recovery ofthe patient. Surgical procedures are conducted by remote manipulation and dissection Within the closed confines ofthe abdominal cavity or extapertoneal space under visual control va telescopes, video cameras and eleision Advantages of laparoscopy Inadditon to avoiding large, painfl access wounds of conventional surgery, laparoscopy allows the operation to be carried out with ‘minimal parital trauma with the avoidance of exposure, cooling, desiccation, handling, and forced retraction of abdominal tissues land organs. Thos the overall traumatic assault on the patient i ‘reduced drastically, and asa result ofthis: 4 Disadvantages and limitations of laparoscopy ‘+ Postoperative pain, ileus and wound complications such as infection and dehiscence are reduced and recovery accelerated. ‘+ “Abdominal adbesion formation, which may become the source ‘of recurrent pain, inestinal obsteuction and female infertility is reduced. ‘Surgically induced immunosuppression, which may have import ant implications particularly in cancer surgery, is decreased. + Postoperative chest complications are reduced. * Cosmetic results are greatly improved. (Other advantages of laparoscopy inch: + Visual enhancement by dhe magnifying effect of the telescope and improved exposure in places such asthe pelvis and subphrenic spaces 4 The greatly reduced contact with patients blood and body Aud. ‘This has important implications for both patent and surgeon in relation tothe transmission of veal diseases. Disadvantages and limitations of laparoscopy ‘The main difculies with laparoscopy emanate from the necesiy + insufflate the peritoneal cavity or extraperitonal space with gs, and access the space via needle and trocar inserted through the abdominal wall. Surgeon-elated difficulties include eye and hand ‘co-ordination andthe remote nature ofthe surgical manipulation, loss of direct hand manipulation and tactile fedback and the two. ‘dimensional image provided by the current camera systems Diathermy injures are a particular potential hazard. However, appropriate taining and experience, open technique laparoscopy, and the development of beter instrumentation including three- dimensional video endoscopy and exploratory ultrasound probe will ‘minimize these dificulis, “The disadvantages of laparoscopy include: ‘+The need to purchase and maintain expensive high technology esuipment. + Laparoscopic procedures require more technical expertise and ‘take longes, a leat initially, than an open approach. Potential injury to the vessels and viscera as the result of needle-cannula insertion, inappropriate instrumentation and dia- thermy burns. * The insufflation may cause postoperative abdominal pain and shoulder tip pain not uncommonly; and gas embolus, deranged Cardiovascular function, tension paeumothorax, and sigaficant Ihyperearbia very rarely Section 1: Introduction + Haemostasis can be difficult to achieve because of technical dlfcuties and because blood obscures vision by absorbing ight. ‘Intact organ retrieval, particularly of tumour containing organs, is seriously limited Contraindicationsirisk factors Absolute 1 Inability ro tolerate general anaesthesia or laparotomy: (a) Cardiovascular (b) Respicatory (6) Uncorrected congulopathy (€) Others. Certain laparoscopic procedures, such as diagnostic and minor surpcal procedures, may be performed under regional or local Anaesthesia 2, Major haeorthage requiring iesoving procedures exped- tiously: (@) Trauma () Ruprured aneurysm (6) Postoperative, 13 Intestinal obstruction (severe distension) Relative 1 Unteanedinexperienced surgeon. 2 Inadequate equipmenvinstrument, assstanss, time 43. Severe cardiopulmonary diseases Risk of CO, pneumopertoneum: ‘+ Increases pressure on diaphragm ‘+ Reduces venous return which leads to lower cardiac output ‘+ Hypercarbia + Arrythmia ‘+ Head-down position increases venous pressure upper half of boy 4, Coagulopathy Risk of bleting ‘Bleeding is technically dificult control laparoscopically because of vessel retraction, the limited ability to apply direct pressure, and limited access. 2 The ability to aspirate blood clos is limited by the diameter ofthe suction probe. Containdicationsrik factors Blood obscures the view because i absorbs light + Direct view further mpaied by brik haemorthage splashes ‘onthe telescope, and smoke and vapour generated by diathermy. 5. Obesity ‘Risks: (a) anaesthesia and surgery in general (b) Thick abdominal wal: + Creates dificult wit insertion of needle and trocar Impedes manoeuvrability ofthe portvinstruments. ‘+ Requires high insufflation pressures. *Diminshes the visualization of abdominal wall vessel and increases risk of bleeding by direct vessel puncture ‘because of diminished transillumination and excess adipose (6) Thick omentum and mesentery further impedes manipulation and visibly, {6 Abdominal wall pathology Hemia risks: (a) hernia crates difficulty with insertion of needle and trocar ‘in conventional port sites such as the umbilicus with the consequent risk of injury tothe bowel. {b) Obstructed hernia: ‘there ie dificlty with laparoscopic reduction; ‘+ pneumoperitoneum further compromises the circulation ofthe stangulated organ, (6) Embeyonic remnants such asthe vtello-intestinal duct and turachus may cause dificulty during placement of needles and ports. 7, Intra-abdominal pathology. Abdominal adhesions: risks: ‘+ injary to bowel, omentum, mesentery and vesels at needle! cannula insertion; ‘+ difculry in creating an effective pneumoperitoneums 1 poor view from excessive searrings, + prolongs the procedute because ofthe nee for adhesilyss. Incestinal obstructions (mild/moderate distension) Risks: distended loops: ‘injury to bowel and mesentery at needlelrocae insertion; diminishes view and working spaces + impedes manocuvrabilty of and around the intestine. Advanced peritonitis: risks: ‘+ intestinal obstractionileus (as above); ‘+ poor view and inability to localize the ste of perforation by fibrinovs adhesions Significant aneurysm Risk: bleeding from needetroca introduction Section 1: Introduction Large benign lives, spleen and other abdominal mass: sks: injury for needletrocar introduction and instrument ‘diminishes view and working space. Pregnancy sks: (a) Mother and fers. ‘general anaesthetic and operativ ‘unknown effect of pneumoperitoneum and CO,.. (b) Pregnant uterus: 4 injury from needletrocar placement and instrument ‘manipulation; 1 diminishes view and working space. Malignant diseases: sks: (a) inadequate acces. (b) Restricted intact organ retrieval, + contamination may preclude histological staging. (c) Gas insfflation may cause spread of malignant cells ‘Combined laparoscopy and open surgery ‘This approach combines the inherent minimally invasive natute of laparoscopy, and the speed and simplicity of open surgery in situations where the laparoscopic approach alone may prove technically dificult nd time consuming. Current indications include: 4 Inexperienced surgeon, + Laparoscopy as a preliminary measuee to diagnose and localize the pathology: (a) Trauma (b) Acute and chronic abdominal pain (e) Peritnitis (4) Malignancy (e) Intussusception (Jaundice (g) Undescended testes and intersex anomalies (h) Others ‘+ Combined procedures: (a) Abdominoperineal approaches for anorectal surgery and colon pulthrough. (6) Abdominothoracocervical approaches for gasto-oesophageal roscopicasisted vaginal hysterectomy (4) Upper and lower urinary tac surgery when nephrectomy is Physiological changes during laparoscopy {e), Abdominoscroal approaches to the testes. + Intact organ retrieval: (a) Cancer teatment (b) Large organs (spleen, kidney) (6) Large segment bowel resection such as total colectomy. ‘+ Manipulation, resection and anastomosis especially in intestinal surgery and rectopexy. ‘+ Complications of laparoscopic surgery. Physiological changes during laparoscopy Although the surgical technique of laparoscopic surgery is of a ‘minimally invasive natore, a numberof physiological changes occur as a result of creating a CO, pneumoperitoneum/pneumoext peritoneum, and postural changes involved in patient positioning ‘These changes may be particularly noticeable in elderly and very young patients, and significant in those with pre-existing diseases such as cardiovascular, pulmonary and neurological disorders. In addicion, other pathophysiological changes related to access and ‘nsrument injuries leading to bleeding, gas embolism oe peritonitis ‘may occur. Irmust be remembered that conventional open surgery 00, has significant effects on body physiology as the result of ‘wound related trauma and pain, pulmonary dysfunction, bowel dys- function from exposure and handling, endocrine and meabolic changes, as wells postural changes required for optimal surgical aces Respiratory changes + Changes in pulmonary function occur with the administration of any general anaesthetic + "Functional residual capacity (FRC) is reduced by diaphragmatic displacement and splinting, and changes in intrathoracic blood volume develop as the result of pneumoperitoncum and Tren- ‘elenburg positioning. This results in small airway collapee which in tur lends to atelectasis, pulmonary shunting snd hypoxemia, ‘Diaphragmatic displacement will also lead ta significant sein peak airway prestre, increase in physiological dead space and a eduction of up 10 s0% in total ling comphance. Despite these, ‘only minor moxifations in gas exchange occurs unless there is ‘pre-existing cardiopulmonary disease when greater changescan occur