Minimally Invasive Surgery

Juan CendanMedical Student Lecture

Background

Cystoscopes – early 1800s Laparoscopy – early 20th century Laparoscope with video camera –

1980’s 1985 first lap chole (France)

Physiology

Increased intra-abdominal pressure Effects (similar to intra-abdominal

“compartment syndrome”): Ventilation Decreases venous return Reduces renal perfusion Increases intracranial pressure

Balance between cardiac function and volume status

Physiology - Exposure

Gas used is CO2 Can be a problem for patients with

COPD Alternates: helium, air, NO, gasless

Patient position Pressure points

Obesity Securing patient

Benefits

Decreased pain Attenuated stress response Early return to ambulation

Pulmonary Effects

Organ System Physiologic Effect Potential Outcome

Pulmonary 1. ⇧peak airway pressure

2. ⇩pulm compliance

3. Superior displacement of diaphragm

4. ⇧end-tidal CO2

1. Barotrauma2. ⇧ pCO2 or

⇩pO23. ⇧ pCO2 or

⇩pO2

4. Acidosis

Circulatory Effects

Organ System Physiologic Effect Potential Outcome

Circulatory 1. Direct effects - ⇧CVP, CWP, SVR (afterload), MAP

2. Indirect effects – arteriolar dilation and myocardial depression

3. Indirect effects – sympathetics, renin-angiotensin

1. ⇧cardiac work2. ⇩blood

pressure3. ⇧ Blood

pressure and cardiac output

4. ⇩ Urine output

⇧

General Complications of Laparoscopy

Injury to adjacent organs: Bleeding solid organs Vascular injuries Bowel injury (puncture, cautery) Bladder/uterus injury

Access site complications Port site hernia Wound infection

Trocars

General Complications, con’t

Specimen removal Port site cancer Splenosis Endometriosis

Pneumoperitoneum Pneumothorax Pneumomediastinum Gas embolus Subcutaneous emphysema

Specific cases

Major vascular injury Rare 0.02% - 0.3% incidence but 15%

mortality R Common Iliac is most common injury

due to location beneath umbilicus Open vs Veress technique

Specific operations

Cholecystectomy Indications are same Technical concerns:

Bile duct injury 0.36%

0.21% with cholangiogram 0.43% without

Bile duct exploration Role of ERCP IO BDE

Lap Chole

Delivering the gallbladder

Inguinal hernia

Traditional inguinal approach with mesh (Lichtenstein procedure)

The view from behind the abdominal wall

Inguinal Hernia

Appendicitis

Appendix locations – benefit of laparoscopy

Dissection of the mesoappendix

Dividing the appendix

Stapled

Looped

Nissen step-by-step

Step 1: The operating surgeon stands between the patient’s legs while the camera operator stands to the patient’s right and the second assistant assumes a position on the patient’s left.

Step 2: Circumferential blunt dissection of the esophagus at the level of the hiatus will allow for the anterior retraction of the esophagus with the left hand dissector, allowing for further posterior dissection of the esophagus. The posterior ‘window’ is then identified with careful blunt dissection posterior to the esophagus just anterior and lateral to the left crus.

Step 3 : A space just superior to the free edge of the left crus is dissected free to allow for closure of the hiatus. This space is often referred to as the cave.(Reprinted from Ferguson MK: Atlas of Esophageal Surgery, in: Digestive Tract Surgery: A Text and Atlas, Bell RH et al, eds, 1996, Philadelphia, Lippincott William & Wilkins, p 137, with permission.)

Step 4: After the crura have been adequately identified and dissected free for a distance of 2 to 3 centimeters, the hiatus is closed using from 1 to 4 2-0 Prolene sutures.

Step 5: Using the harmonic scalpel, the short gastric vessels are divided to mobilize the fundus. (Reprinted from Townsend et al: Hiatal hernia and gastroesophageal reflux disease, in Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 16th Edition, 2000, Philadelphia, Saunders, p 761, with permission

Nissen step-by-step

Step 6: Graspers are used to identify a point on the fundus approximately 15 cm distal to the Angle of His. This point is then placed into the open Babcock clamp and slowly pulled behind the esophagus through the window.

Step 7: The shoe-shine maneuver is used to ensure that the fundus slides freely posterior to the esophagus and is of appropriate length.

Step 8: The wrap is sutured into place using a single U-stitch of 2-0 Prolene buttressed with Teflon pledgets tied in an extracorporeal manner. A 50-56 Fr Maloney bougie may be introduced prior to sizing the wrap and is removed before placing the sutures.

Step 9: A 3-0 silk suture is used to further secure the wrap and is most easily tied intracorporeally.

Nissen step-by-step

Reflux surgery

Conclusions

Laparoscopy is a TOOL Used properly allows us to do many

operations that were once done open General Consensus is that return to

activity is improved as is abdominal wall wounding

Trade off is visualization and degree of surgeon comfort with exposure and instrumentation

Risk/benefit should always favor opening if safety is enhanced