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1、,LAPAROSCOPICSURGERY,JanePBradleyHendricks,RGN,BSE(hons),MCS,IndependentNursePresc,riber,SurgicalCarePractitioner,LaparoscopicSurgery.,ColchesterGeneralHospital,SHORT HISTORY,?,1982 Semm performed first Laparoscopic,Appendicectomy.,?,1987 Mouret performed first,Laparoscopic Cholecystectomy.,?,1992 F
2、irst UK Laparoscopic Training,centre established.,LAPAROSCOPIC SURGERY,“KEYHOLE SURGERY”,MINIMALLY INVASIVE SURGERY,MINIMAL ACCESS SURGERY,What operations can we do,laparoscopically?,Diagnosis,Crohns Disease,Diverticulitis,Rectal Prolapse,Benign renal disease,Gastric Obstruction,Some Splenic disorde
3、rs,Operation,Bowel resection,Bowel resection,Repair of Prolapse,Nephrectomy,Bypass,Spleenectomy,What operations can we do,Laparoscopically,Diagnosis,Gallstone,Appendicitis,Hernia,Adhesions,Perforated ulcer,Hiatus Hernia,Operation,Cholecystectomy,Appendicectomy,Hernia repair,Division of adhesions,Clo
4、sure of perforation,Hiatus hernia repair.,What operations can we do,Laparoscopically,Diagnosis,Colorectal carcinoma,Caecal carcinoma,Colonic carcinoma,Gastric carcinoma,Oesophageal carcinoma,The list is endless!,Operation,Anterior resection/APR,Right Hemicolectomy,Left/Sigmoid Colectomy,Gastrectomy,
5、Oesophagogastrectomy,Principle Differences between,Laparoscopic and Open Surgery,FOR THE PATIENT,?,Post operative pain related to size of incision-,smaller incisions=less pain.,?,Less Handling of intestines results in little or no,disturbance of normal function.,?,Avoidance of the trauma of abdomina
6、l wall injury,by the incision allows rapid return to normal,activity,?,No incision allows early return to more strenuous,activities:driving,lifting,sport etc.,Principle Differences between,laparoscopic and open surgery,FOR THE HOSPITAL,?,Initial capital costs to establish laparoscopic,surgery in the
7、 order of,30,000-,40,000,?,Reduced overall costs by shortening of,hospital stay e.g.cholecystectomy reduced,from 5 to 1 day,hiatus hernia repair reduced,from 7 to 3 days.,Principle Differences between,laparoscopic and open surgery,For the Surgeon,?,Magnified view often better than obtained via an,in
8、cision allows precise dissection.,?,Altered(but not absent)tactile response,?,Two dimensional(flat screen)view.,?,Usually(but not always)longer operating time,?,Need to develop entirely different operating,technique,?,Adaptation of principles of open surgery to,laparoscopic surgery.,Instruments,?,Re
9、design of instruments for laparoscopic,use.,?,Instruments for open surgery in general 6,10”in length built around a box joint.,?,Laparoscopic instruments in general 15,18”,in length with an articulated connecting rod,between handles and scissor blades,jaws,etc.,Equipment Necessary for MAS,Camera,Lig
10、ht Source,Insufflator,TV Monitor,Telescopes,Light Guide Cable,Apart from the,insufflator the system,will work better if all,the components are,from the same,company as one piece,talks to another,CAMERA,?,These can be single chip or 3 chip.,?,CHIP:thois is also called a charged coupled,device in shor
11、t,CCD.,?,These are flat silicone wafers with a matrix,a grid,of minute image sensors called pixels.,?,White balance and sometimes black balance,?,Sleeve it dont soak it!,?,Light Source,?,Halogen or Xenon,cold light but beware can still,burn holes in drapes esp.disposable and burn,patients skin if le
12、ft on the abdomen.,?,Brightest to darkest measured in units of decibels.,?,Automatic illumination,does it talk to the camera,and are the necessary leads plugged in.,?,Lamp life meter,look at it.Is it nearly out?EBME,keep the spares and they change it.,?,White balance by making sure white is correct,
13、then all the colours through the spectrum are,correct.,Insufflator,?,CO2 because this has the same refractive index as,air,so doesnt distort the image and is non,combustible.,?,Intraabdominal pressure run between 10 and 13,mmhg.,?,Use disposable filter and tubing for each patient.,?,High flow insuff
14、lators(35 litres)output,determined by size of outlet.,?,Ensure you know how to change a cylinder and,were they are stored.,TV Monitors,?,Usually a 20”screen.,?,If your monitor has MD in the spec.they are,compliant with th lines.e hospital electrical safety,systems for example Son 1343-MD.,?,You can
15、use a standard TV but it must be run,through an isolated transformer.,?,Horizontal resolution is the number of vertical,lines.,?,Vertical resolution is the number of horizontal,lines,?,More lines of resolution,better detail of picture.,Telescopes,?,Come in varying sizes,laparoscopes usually 5mm,or 1
16、0mm.,?,Diagnostic 3mm scope available but not in general,use in this hospital.,?,Made up of a rod and lens system.,?,Bundles of fibres,incoherent carry light and,coherent carry image.,?,Wide range of angles available 0 and 30 degree,are fairly standard.,?,All laparoscopes are autoclavable and can go
17、 thru,steris,no ultrasonic bath.,Light guide Cables,?,Different diameters,?,Fibre light cable,?,Buy auroclavable,?,Dont bend to acutely as will break fibres.,?,Check when you plug them in are all the,fibres are okay.,?,Condensers,Instrumentation,?,SINGLE USE:breaking the Law if you reuse it on,anoth
18、er patient.,?,Reusable take apart.,?,Need an ultrasonic washer to effectively clean,them,not for telescopes.,?,Dont put 5mm cannulated instruments into a,bench top autoclave that does not have a vacuum:,vacuum is required to remove all air form lumen,of instrument.,?,Ports 5 and 10mm are the most co
19、mmon,make,sure the right trocar is in port and is it sharp.,Electrosurgery,You should be aware of the following,potential situations:,?,Insulation failure,of the active electrode.,?,Direct coupling of current,to other,instrumentation by direct contact.,?,Capacitance,which may be created by two,elect
20、rical conductors separated by an,insulator,Appropriate safety standards can be maintained if,surgeons adhere to the following guidelines,?,Use a low voltage waveform(cut instead of coagulation)whenever,possible.,?,Use the lowest possible power setting that will deliver the desired,tissue effect.,?,E
21、nsure that insulation on reusable and disposable instrumentation is,intact and uncompromised before activating.,?,Do not activate the electrode in air space(open circuit activation).,Activate the generator only when the active electrode is in direct,contact with target tissue.,?,Do not activate elec
22、trode when in contact with other instruments.,?,Use bipolar electro surgery were appropriate,good for coag.But not,for cutting tissue.,and most importantly,?,Do not use hybrid trocars that are comprised of,metal and plastic components.For the operative,channel use all metal or all plastic systems.,E
23、lectrosurgical energy should not be passed,through hybrid systems.,?,Use available technology such as an active,eletrode monitor(AEM)to help eliminate concern,with insulation failure and capacitive coupling.,Electrosurgery Laser,?,Insulation failure,?,Direct coupling,?,Capacitive coupling,?,Current
24、pases through the,body-effect on,pacemakers.,?,Return electrode burns,?,Toxic smoke,?,Charring of instruments,?,Toxic smoke,?,Expensive,?,Specialised theatres,required.,?,Variable penetration,WATER JET,?,Excessive mist,?,Poor depth control,Ultrascision,Electrical generator(the box),This adjusts the
25、amount of electrical energy being delivered and,monitors performance.,Transducer,This is where electrical energy is converted to the ultrasonic waves.,The frequency is fixed however the amplitude alters with the power,input.the transducer is located in the hand piece and is connected to,the generato
26、r by an electrical cable.,Dissection Instrument(peripheral hand piece),A metallic rod is coupled to the transducer and vibrates at the,prescribed frequency(i.e.55kHz).The tip of the rod contacts with the,surface tissue.,Principles of Piezo Electronics,?,The ultrasound waves are created by electrical
27、,energy hitting a negatively charged crystal that,vibrates(expands and contracts)at a particular,frequency.These crystals are disc shaped and,made of ferroelectric ceramics.A pair of discs,“coupled”together produce a sinusoidal wave,form.This coupling results in a harmonic,waveform that is of high e
28、lectroacoustic efficiency.,Lateral Thermal Damage,?,Ultrasonic dissectors are designed to operate at 60-80 Celsius and not,destroy cells by rapidly heating intracellular water to stream.The,process of vaporisation occurs at very high temperatures with cutting,mode electro surgery.The process of coag
29、ulation begins at very high,temperatures with cutting mode electro surgery.The process of,coagulation begins at temperatures above 70 Celsius where proteins,are denatured and collagen is converted to glucose.Occasionally the,temperature at the tip of the ultrasound dissector may reach up to 120,Cels
30、ius however this is well below the 200 Celsius required to,carbonise tissue with electro surgical energy(fulguration).Hopefully,by dividing tissue at lower temperatures the amount of lateral thermal,damage is minimal.,Is it Safe?,?,Colorectal Cancer-COST trial and,CLASSIC.,?,Reoperation rate,?,Readm
31、ission rate.,?,Mortality,?,Morbidity.,Enhanced Recovery programme,?,Henrik Kehlet,Denmark,?,Robin Kennady,Yeovil,?,Prof Motson,Mr Arulampalam and,MrAustin,Colchester.,Key points ERP,?,No fluid overload,?,Eating and Drinking ASAP,?,Out of bed ASAP,?,IV fluids D/C as patients need to be thirsty to,dri
32、nk!,?,Urinary Catheter out,then they have to walk to,bathroom!,?,Avoid morphine analgesia,slows down gut and,induces sleep.,Postoperatively;What do the,Patients Think.,?,They like it,?,Day case Lap Chole:how it works.,?,Other hospitals Same Day Surgery?Day,Surgery.,Equipment,Cholecsyectomy,Explorati
33、on of CBD,?,Performed,laparoscopically,?,same time as,cholecystectomy,?,Alternative ERCP,Nissen Fundoplication,Inguinal Hernia Repair,Appendicectomy,“My God,Jim,we cant,leave him in the hands of,20th century medicine.,Those butchers will use,needles and knives and,cut open his belly and,chest.It is still the dark,ages.You have no idea,what those barbarians will,do.”,Dr.James McCoy,Starship Enterprise,Star Date 2394.3,Questions?,Thank You For Your Time,
