*Aim:
To accomplish surgical therapeutic goals with minimal somatic and psychological traumaIt is
-Less invasive
-Less disabling and disfiguring than conventional technique
-With increasing experience they offer cost effectiveness both to health services and to employers by shortening operating times and shortening hospital stay .
Extent of minimal access surgery
-Laparoscopy
-Thoracoscopy
-Endoluminal endoscopy
-Perivisceral endoscopy
-Arthroscopy and intraarticular joint surgery
Surgical trauma in open and laparoscopic surgery
-The wound in open surgery can cause infection ,dehiscence,bleeding, herniation,and nerve entrapment.
-The pain it cause prolong recovery time ,decrease motility and increase incidence of pulmonary collapse ,chest infection and deep vein thromboses.
-Mechanical and human retractor cause trauma and localized damage leading to pain and necrosis,infection while during laparoscopy the retraction is provided by low pressure pneumoperitoneum giving a diffuse force applied gently and evenly over the whole body wall causing minimal trauma.
-The morbidity from exposure of any body cavity to the atmosphere causing cooling and fluid loss by evaporation.
- The incidence of post surgical adhesions has been reduced by the use of laparoscopy, because there is less damage to delicate serosal covering.
-By open surgery there is disturbance of the peristaltic activity of the gut and provoke adynamic ileus.
-With minimal access surgery the trauma of access and exposure is reduced while visualisation is magnified and imroved.
Limitation of minimal access surgery
The instrument are longer and sometimes more complex to use.
Haemostasis may be very difficult to achieve endoscopicaly.
Some of the procedure performed are more technically demanding and slower to perform.
Loss of tactile feedback.
Large piece of resected tissue e.g. LUNG COLON.
Tumor implantation.
Preoperative Evaluation
Preoperation is very similar to that for open surgery and aim to ensure :
The patient is fit for the procedure.
The patient is fully informed and consented.
Operative difficulty is predicted where possible.
Appropriate theater time and facilities are available.
HISTORY coagulation disorder or previous abdominal operation.
physical examination is required .
Sever chronic obstructive airway disease and ischemic heart disease.
Prophylaxis against thromboembolism is some time necessary specially in lengthy operation and obesity .
Post Operative Care
Nausea is common ,rarely sever.
Shoulder pain,it is reffered from the diaphragm.
Abdominal pain in one or more of port site and is worse if there is a haematoma formation.
Analgesia voltaren supp.100mg should be given at time of operation and repeated 2-3times post operatively for more sever pain.
Oral fluid, patient can start taking oral fluids as soon as he is conscious.
Oral feeding light meal can be taken 4-6 hrs after the operation.
Discharge from the hospital,it is better that the patient be kept in over night and discharged next morning.
The Future
Although there is no doubt that minimal access surgery has changed the practice of surgeon,it has not changed the nature of disease.
The basic principle of good surgery include-
Appropiate case selection.
Exellent expoture
Adequate retraction.
High level of technical expertise.
Improvement in instrumentation and the development structure training program are the key to the future of minimal access surgery.