Laproscopic surgery

LECTURE 4

Dr. Ali Kadhim Consultant surgeon

Laproscopic surgery ( Minimal access surgery )

Modern technique that aim to accomplish surgical treatment with minimal somatic and psychological trauma . It has reduced wound access and less disfiguring .

Advantages Of laproscopic surgery

1. Less disfiguring ( no more scar ) 2. Decrease in wound size . 3. Reduction in wound infection , bleeding , dehiscence and hernia formation . 4. Decrease in wound pain . 5. Improved mobility . 6. Decrease wound trauma and heat loss . 7. Improved vision . 8. Less post-operative adhesions and ileus . 9. Short hospital stay . 10. cost effective .

Technique of Laproscopic surgery :

The rigid endoscope that introduced through a metal sleeve ( port ) into the peritoneal cavity which inflated with Co2 to produce , pneumoperitoneum , Another ports to introduce surgical instruments to the abdominal cavity .

Limitations of minimal access surgery :

- Reliance on remote vision and operating . - Loss of tactile feedback ( sensation and palpation on the mass , lesion , ….. ) - Dependence on hard-eye coordination . - Extraction of large specimens ( uterus , spleen , cyst , …. ) - Implantation of malignant cells . - Locoregional hypoxia ( use Co2 )

Preparations for lapr. Surgery

- Fitness for G.A ( to control DM , HIN , cardiac , disease , chest infection ) - Previous surgery ( scars , adhesions ) - Body habitus , obesity and skeletal deformity . - Normal coagulation . - Thromboprophylaxis . - Informed consent .

Surgical principles

- Care in creation of pneumoperitoneum . ( open or close techn. ) - Adhesolysis ( Remove adhesions ) - Adequate exposure of operative field . - Avoidance and control of bleeding ( Haemostasis ) - Avoidance of organ injury . - Avoidance of diathermy damage . - Saline wash at the site of operation . - After deflation , proper repair and suturing of port wounds .

There are 2 methods for creation of pneumperitoneum :

- Open method require surgical dissection ( wound 1 cm ) or the use of Hasson port - Close method involves blind puncture using a verres needle .

Post operative care :

After lapr. Surgery patient may complain of nausea , vomiting , shoulder pain , abdominal pain ( epigastric or at port site ) and rarely bleeding and haematoma formation .

Postoperative care require

- I.V fluid ( Glucose water or glucose saline ) - Analgesia ( Pethidine or Tramadol , Diclofenac injection or suppository and when there is contraindication we use paracetamol vials . - Antibiotics ( I.V. ) to prevent infection ( e.g. ceftrioxone ) . - Nasogastric tube or Foley's catheter , only if indicated and for short period . - Oral fluids , we start as early as possible , within hours . - Care for the drains . - Discharge from hospital within 24 – 48 hours ( and according to the state of the patient and type of the operation , may be more ) - Early mobility and convalescence , and the role of antithrombotic prophylaxis .

Common laproscopic procedures

- Laproscpoic cholecystectomy . - Lapr. appendecetomy . - Lapr. hernia repair ( with mesh ) - Lapr. antireflux surgery , and gasterectomy . - Lapr. splenectomy , adrenaliectomy , nephrectomy , variscoectomy . - Lapr. colectomy and bowel resection . - Lapr. cysts excision and i.n. biopsy - Diagnostic laproscopy . - Lapr. oopherectomy and hysterectomy