Dr.Saifuddin Ahmed
IMO
Department of surgery, Unit 1
Chittagong Medical College Hospital
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What is laparoscopy and its applications
History
Instruments ( details)
Indications and contraindications
Physiological changes
Port of laparoscopy
Complications during operation
Commonly practiced laparoscopic surgeries
Some pictures of laparoscopic appendicectomy
Definition
• It is a minimally access procedure allowing
endoscopic access to peritoneal cavity after
insufflation of gas to create space between the
anterior abd. Wall & viscera for safe manipulation
of instruments & organs.
TYPES
1 Intraperitoneal
2 Extraperitoneal
3 Abd wall retraction (gasless laproscopy)
4 Hand assisted (Hassans tech.)
HISTORY
• George Kelling used cystoscope to
observe abd organs of dogs—
CYSTOSCOPY
1910 – Swedish physician Hans Christian
Jacobaeus used this procedure in man and
coined the term – LAPAROSCOPY
• 1987 – Mourett in France successfully removed a diseased gall
bladder laparoscopically
•
INSTRUMENTS USED
 Zero degree laparoscope
 Cold light source (Halogen and Xenon lamp)
 Camera ( 3chip camera commonly used with high resolution
 Video monitor to display images
 CO2 insuffulator
 Long fine dissectors
 Hooks and spatulas with cautery for dissections
 Clip applicators
 Needle holders
 Veress needle
 Trocars of different sizes – 10mm, 5mm
 Suction irrigation apparatus
 Reducers to negotiate smaller instruments through larger ports
Telescope
 There are three important
structural differences in
telescope available
1. 6 to 18 rod lens system
telescopes are available
2. 0 to 120 degree
telescopes are available
3. 1.5 mm to 15 mm of
telescopes are available
Trocar
 The trocar has a blade with
a shaft and body.
 The body includes a
pointed tip which makes the
initial incision in the
abdominal wall of the
patient.
(Trocar diameters range from
2mm-30 mm)
Most common trocer is 5mm
& 10mm
Optic Cables
 These cables are made
up of a bundle of
optical fibers glass
thread swaged at both
ends.
 The fiber size used is
usually between 10 to
25 mm in diameter.
 They have a very high
quality of optical
transmission, but are
fragile.
Dissecting & Grasping Forceps
 Atraumatic
 KELLY atraumatic
 Atraumatic, with hollow jaws
 MANGESHIKAR Grasping
Forceps, serrated
Laparoscopic Hook
 It is used to separate adhesions,
 Used for diathermy purpose,
 To give traction to any organ.
Scissors

HOOK SCISSORS, single action jaws

METZENBAUM SCISSORS, curved,
length of blades 12-17 mm, widely
used as an instrument for mechanical
dissection in laparoscopic surgery.

STRAIGHT SCISSOR can give
controlled depth of cutting because it
has only one moving jaw.
General instruments
 Reusable three-piece design
 Available in 2 mm, 3 mm,
3.5mm, 5 mm and 10 mm sizes,
with lengths of 20 cm, 30 cm,
36 cm and 43 cm.
 Choice of handle styles.
 Fully rotating 360° sheath.
 No hidden spaces that can trap
operative blood and tissue
debris.
Gas Insufflators

Pneumoperitoneum
is created upto
15mmHg which
distends the
abdominal cavity for
proper visualization
Gases used to create pneumoperitoneum :
•Air
•O2
•CO2 : most common
•N2O : prefered for patients with cardiac disease
•He, Ne, Ar ( new )
Why CO2 is commonly used
to create pneumoperitonium ?
Readily available
Cheaper
Easily absorbed by tissues
Quickly released via respiration
Technique

Head end of the table is lowered to have easier
insertion of needle scope
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Pressure bandages are applied to both legs to
improve the venous return

Ryle’s tube and foley’s catheter are essential
before insertion of the trocars

Pneumoperitoneum is created using veress needle
through umbilical incision
PHYSIOLOGICAL CHANGES
Physiological
changes
pneumoperitoneum
Physiologic changes due to
pneumoperitoneum
 CO2 causes hypercarbia, acidosis and hypoxia
 Pneumoperitoneum exerts pressure on the IVC,
decreases the venous return and so the cardiac output
 Increase the arterial pressure
 Compromises the respiratory function by compressing
over the diaphragm imparing the pulmonary compliance
Laparoscopic Port Positions
 PRIMARY PORT POSITION
• Attractive primary port is the umbilicus because of
1. central location and
2.the ability of the umbilicus to hide scars
• Umbilicus is a naturally weak area due to absence of all the
layers
• Its location is at the midpoint of the abdomen’s greatest
diameter.
SECONDARY PORT POSITION
• Varying of operation
• According to the surgeon preference
Basic Diamond Concept of Port
Position
Mainly two port 5mm and 10mm port
Laparoscope is inserted through the umbilical
port (10mm port)
 Clip applicator 10mm port is essential
Additional ports ( 3-4) through trocars are
placed depending on the procedures may be
5mm or 10mm port
Basic Diamond Concept of Port
Position
(5mm)
 Port position for cholecystectomy
(10mm)
(5mm)
 Port position for appendectomy
Commonly practiced laparoscopic
surgeries
Laparocopic cholecystectomy
Laparoscopic appendicectomy
Laparoscopic inguinal hernia repair
Laparoscopic hysterectomy
Less commonly practiced
laparoscopic surgeries
Laparoscopic perforation repair
Laparoscopic splenectomy
Laparoscopic vagotomy and
gastrojejunostomy
Laparoscopic urologic surgeries
Diagnostic laparoscopy
Needle laparoscopy of 2mm sized becoming popular
Indication
• Acute pelvic conditions
• Tubal pregnancy
• Ovarian diseases
• Infertility
• Staging of the malignancy
• Biopsy from the tumors
• In chronic pain abdomen where ultrasound,
endoscopies, barium studies are negative
CONTRAINDICATIONS
1. Absolute - none
2. Relative
i) severe COAD
ii) recent MI
iii) ventriculoperitoneal shunts
iv) Increased ICT
v) extensive organomegaly
vi) CHF
Advantages of laparoscopic surgery
1. Less post operative pain
2. Faster recovery time
3. Shorter hospital stay
4. Smaller scars
5. Less internal scarring
6. Less risk of wound infection
and incisional hernia
7. Better visualization of anatomy
Laparoscopic Surgery
Laparoscopic appendicectomy
Complications
Insertion Related :
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Major vascular injury
GI Injury
Bladder injury
CO2 embolism
Abdominal wall haemorrhage
Post Insertional :
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GI perforations
Laceration & bleeding from solid organs
Abdominal wall hernia
Pneumoperitoneal Related:
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CO2 embolism
Hypercarbia
Respiratory acidosis
Subcutaneous emphysema
Renal failure
Venous thrombosis
Pneumothorax