Principles of Laparoscopic surgery

1. Principles  of Laparoscopic surgery ????????????? ??????????

2. Learning Objectives To understand the principles of laparoscopic surgery To be aware of the advantages and dis advantages of this type of surgery To prepare of patient safety for laparoscopic surgery To learn the procedures when laparoscopic surgery is appropriate To care for the patient postoperatively

3. Definition Minimal access surgery is a marriage of modern technology and surgical innovation that aims to accomplish surgical therapeutic goals with minimal somatic and psychological trauma

4. Extent of minimal access surgery Laparoscopy Thoracoscopy Endoluminal endoscopy Perivisiceral endoscopy Arthroscopy and intra-articular joint surgery Combined approach

5. Surgical Trauma in Open and Laparoscopic Surgery The wound is often the cause of morbidity,including,infection,dehiscence,bleeding, herniation and nerve entrapment

6. Advantages of minimal access surgery Decrease in wound size Reduction in wound infection,dehiscence,bleeding,herniation,nerve entrapment Decrease in wound pain Improved mobility Decreased wound trauma Decreased heat loss Improved vision

7. Limitations of minimal  Access surgery Reliance on remote vision and operating Loss of tactile feedback Dependence on hand –eye coordination Difficulty with hamostasis Reliance on new techniques Extraction of large specimens

8. Preoperative Evaluation Preparation for Laparoscopic surgery Overall fitness; cardiac arrhythmia, emphysema Previous surgery;scars,adhesions Body habitus;obesity,skeletal deformity Normal coagulation Thromboprophylaxis Informed consent

9. Aims to Ensure That The patient is fit for the procedure The patient is fully informed and consented Operative difficulty is predicted when possible Appropriate theatre time and facilities are available

10. Preoperative Evaluation History Examination Premedication Prophylaxis against thromboembolism Urinary catheters and nasogastric Informed consent

11. General Intraoperation  principles Surgical Principles Meticulous care in creation of pneumoperitoneum Controlled dissection of adhesions Adequate exposure of operative field Avoidance and control of bleeding Avoidance of organ injury Avoidance of diathermy damage Vigilance in the postoperative period

12. General Intraoperation  principles Creating a pneumoperitoneum Preoperative problems Previous abdominal surgery Obesity Operative problems Perforation of the gall bladder Bleeding

13. Bleeding How to avoid bleeding -By identifying patients high risk of bleeding -By clear understanding of the laparoscopic anatomy -By careful surgical technique

14. Risk factor predispose to increased bleeding include Cirrhosis Inflammatory condition Coagulation defects

15. Bleeding Bleeding from major vessel Bleeding from the gall bladder bed Bleeding from a trocar site Evacuation of blood clots

16. Principles of electrosurgery during laparoscopic surgery Inadvertent touching or grasping of tissue during current application Direct coupling between a portion of bowel and metal instrument that is touching the activated probe Insulation breaks in the electrodes Direct sparking to bowel from the diathermy probe Current passage to the bowel from recently coagulated

17. Postoperative Care Nausea Shoulder pain Abdominal pain Analgesia Orogastric tube Oral fluid Oral feeding Urinary catheter Drains Skin sutures

18. Principles of Common Laparoscopic Procedures Laparoscopic Cholecystectomy Laparoscopic Inguinal hernia repair Laparoscopic Antireflux surgery

19. THE FUTURE It has not changed the nature of disease The basic principles of good surgery still apply,including appropriate case selection, excellent exposure,adequate retraction and a high level technical expertise If a procedure makes no sense with conventional access, it will make no sense with a minimal access approach

20. THE FUTURE The cleaner and gentler the act of operation, the less the patient suffers, the smoother and quicker his convalescence,the more exquisite his healed wound. Berkeley George Andrew Moynihan