Principles of MIS

ASSOC.PROF. UTHAM MURALI. M.S ; M.B.A.

Principles of Minimal Invasive Surgery

Anesthesia

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Definition

Minimal Invasive Surgery can be defined as the application of

modern technology to minimize the trauma of surgical access without

compromising the exposure of the surgical site, or the safety of the

patient.

Other Names

“ KEYHOLE SURGERY ”

“ LAPAROSCOPIC SURGERY ”

“ MINIMAL ACCESS SURGERY ”

Short History 1901 - Von Ott - First inspection of abd.cavity. 1983 - First lap.app. – Semm, a Ger. gynae. 1985 - First lap.Chole – Erich Muhe, a Ger.

surg. 1987 - First lap.ing.hernia repair – Ger. 1989 - First lap.hyst. – Reich et al. 1990 – “MIS” – Wickman & Fitzpatrick. 1992 – “MAS” – Cuschieri.

Extent of MIS

Laparoscopy. Thoracoscopy. Endoluminal endoscopy. Perivisceral endoscopy. Arthroscopy and Intra-articular Surgery. Combined Approach.

Advantages of MIS

Decrease in wound size / wound pain Improved mobility Improved vision Good Instrument access Reduction in wound infection, dehiscence, bleeding,

herniation, nerve entrapment & adhesions

Limitations of MIS 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

Theatre set -up

Straight – Line Principle

Surgeon opposite to the organ of interest

Assistant opposite to the surgeon

Camera man same side of the surgeon

Monitor positioning

[front / bel.eye level - 25°]

Triangulation - Principle

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Ideal Angles

Tools / Instruments

- 0°/30° Laparoscope- Light source –

Halogen lamp- Camera- Video-monitor- CO 2 insufflator- Veress needle- Trocars- Suction-irrigation apparatus- Working instruments

General Pre-operative Principles

Technique

CO2 - Common

- Creating Pneumo.15 mm Hg

- Laparoscope inserted –

umbilical port

- Abdomen evaluated

- Organs – visualized

- Additional ports placed

- Cheaper

- Readily available

- Easily absorbed

- Released via respiration

- Highly diffusion coefficient

Electro-surgery Principles

Inadvertent touching and grasping.

Direct coupling between the tissue & the instrument.

Break in insulation.

Direct sparking to bowel from the diathermy probe.

Passage of current to the bowel from recently coagulated tissue.

Surgery Principles

Meticulous care – creation of a pneumo.

Controlled dissection of adhesions

Adequate exposure of operative field

Avoidance and control of bleeding

Avoidance of organ injury

Avoidance of diathermy damage

Vigilance in the postoperative period

Preparation for MIS

Overall fitness: card.arrh. / emph.

Previous surgery: scars,

adhesions

Body habitus: obesity, skeletal

deformity

Normal coagulation

Thrombo-prophylaxis

Informed consent

Pneumoperitoneum - Changes

Operative problems

Perforation of hollow

viscus

Bladder Injury

Bleeding From Major Vessel

From Gall bladder bed

From Trocar site

Post – operative Care

Nausea

Shoulder Pain

Abdominal Pain

Analgesia

Oral fluids

Oral feeding

Drains

Contraindications – Relative Compromised cardiac status

Peritonitis

Multiple Abdominal Surgeries

Bleeding disorders

Morbid obesity

III rd Trimester pregnancy

Portal hypertension

Common - Surgeries Diagnostic laparoscopy

Cholecystectomy

Appendicectomy

Repair of all types of Hernia

Hysterectomy

Tubectomies

References

Future is Minimal Access Surgery

Thank You !

Join Hands for Surgical Procedure of New Millennium